Every finding on record at White Acres Wellness & Rehabilitation

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents reviewed for care plans. (Resident #1). The facility failed to ensure Resident #1's care plan addressed wound care. This failure had the potential to affect residents by placing them at risk for unmet care needs.Findings included: Record review of Resident # 1's admission record dated 06/16/2026 revealed a [AGE] year-old male with an admission date of 04/26/2026. Record review of Resident #1's Diagnosis Information dated 06/16/2026 revealed Necrotizing Fasciitis (bacterialinfection that destroys the body's soft tissue, fat and the tissue covering the muscles), and Other specified soft tissue disorder (a medical classification for conditions affecting muscles, fascia, ligaments, and tendons that don't fit into a strictly define category).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive function. Section M- Skin Conditions revealed Resident #1 was receiving surgical wound care and application of nonsurgical dressings. Record review of Resident #1's orders dated 04/26/2026 revealed Wound Care to Right Forearm - Cleanse with NSS, pat dry, apply xeroform, apply ABD pad, wrap with kerlix, secure with tape QOD and PRN. Every day shift every other day and as needed. Record review of Resident #1's care plan revised on 04/10/2026 did not address wound care. An observation on 6/16/2026 at 9:50AM of wound care being performed for Resident #1's right forearm revealed a clean wound, no signs of infection. Wound was cleaned per doctor's orders. In an interview on 06/16/2026 at 2:57pm with LVN A, she stated that the purpose of the care plan was to address the care that the resident was receiving. She stated that if the facility was providing certain care for the resident, such as wound care, this should have been included in the care plan. She stated that the risk could be a delay in care of the resident. She stated that the MDS nurse was responsible for ensuring the care plan was up to date.On 06/16/2026 at 3:16 pm the facility administrator stated MDS nurse was currently on PTO. In an interview on 06/16/2026 at 3:52pm with the DON she stated wound care was supposed to be included in the care plan so that staff know the care that was to be provided to the resident. She stated that the risk could be staff overlooking wound care causing a delay in care. She stated that the MDS nurse and wound care nurse were responsible for updating the care plan and ensuring wound care was addressed.In an interview on 06/16/2026 at 4:06 pm with the Administrator, he stated wound care needed to be addressed in the care plan because it was part of the resident's care. He stated that the MDS nurse was responsible for ensuring that the care plan was updated quarterly, but the whole team was responsible for ensuring it was updated routinely. He stated that the possible risk would be delayed in care of the resident because the staff, especially new staff, could possibly overlook wound care treatment. Review of the facility policy titled Care Planning revised on 06/2020 read in part . To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's, family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident- specific goals that dress the resident's medical, nursing, mental and psychosocial needs.

Based on observation, interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for 1 (Resident #2) of 7 residents reviewed for grievance resolution. The facility failed to ensure they followed their facility policy and procedure on Grievance/Complaints when Resident #2's family member and PASRR Caseworker voiced concerns on 04/09/26 during the care plan conference. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included:Review of the admission Record dated 06/03/26 revealed Resident #2 was originally admitted on [DATE] and re-admitted on [DATE]. Review of the History & Physical dated 06/16/25 for Resident #2 revealed [AGE] year-old male with past medical history of dementia(a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation), complete trisomy 21 syndrome (a genetic condition where a person is born with an extra copy of chromosome 21, that alters how the brain develops, causing physical traits and learning challenges) and seizure disorder. Not oriented x 3. Review of PASRR IDD Evaluation dated 07/07/25 for Resident #2 revealed Intellectual Disability - Yes. Developmental Disability - Yes. Specialized Services Determination/ Recommendations: Self-monitoring and coordinating medical treatment. Self-help with ADLs such as toileting, grooming, dressing and eating. Unclear speech. Sometimes he understood. Review of Quarterly MDS dated [DATE] for Resident #2 revealed, Reentry 06/16/2025. No speech and rarely understand others. Cognitive Skills for Daily Decision Making - severely impaired. Toileting - dependent. Dressing - dependent. Turing & Repositioning in bed - Dependent. Incontinent of bowel & bladder. Active Diagnoses: Non-Alzheimer's Dementia, Anxiety, Downs Syndrome (A genetic condition where a person is born with an extra chromosome causing distinct physical traits and varying levels of learning delays), Seizures. Review of Care Plan revised 02/17/26 for Resident #2 revealed: -Bladder incontinence r/t activity intolerance. Interventions: Encourage fluids during the day to promote voiding responses. Check the resident on rounds and as required for incontinent episodes. Monitor for signs of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, altered mental status, change in behavior, change in eating pattern. Review of Care Plan Conference Note dated 04/09/26 at 2:48 p.m. for Resident #2 revealed, Contributors: Resident Representative, MDS Nurse, Social Worker, PASRR Caseworker. Additional Information: Concerns about being soaked and not changed. Lack of water. Drinking water is not left within reach. Need more help on the floor, not enough staff. Overwhelmed with work. PASRR asked about the IV fluids given last month for dehydration and the UTIs and ABT given for that. Family concerned with the hydration and UTi x 3 .During a telephone interview on 06/03/26 at 3:33 p.m., PASRR Case Worker F stated she and the resident's family member attended a Care Plan Conference on 04/09/26. She stated they reported to the facility short of staff ,Resident #2 was frequently found soaking wet with urine, the resident was not offered water to drink, and was not checked for incontinence on a regular basis. She said they were also concerned about the recurrence of urinary tract infections. She said the MDS Nurse, Social Worker, Therapy Staff and the Nurse assigned to the resident were present during the care plan meeting . She said no one had ever called them back to follow up on what they were going to about the concerns voiced during the care plan meeting on 04/09/26. She said the resident's family member did not want to file a complaint with state office. She said the family member placed a camera in the resident's room and now was doing better with keeping clean and dry. She said she was worried about the recurrence of UTIs, leaving the resident wet for long periods of time and not offering water to the resident.During an interview on 06/03/26 at 11:17 a.m., LVN B stated Resident #2 had intellectual disabilities and was only oriented to person, recognized familiar people, required total care, chairfast, required a Hoyer Lift for transfers, was incontinent of bowel & bladder. She said the resident could not talk. She said the CNAs made rounds every two hours to check for incontinence and offer water to the residents. She said that she was not aware of any concerns related to leaving residents wet for long periods of time.During an observation and interview with CNA G, in the presence of LVN B it was revealed that she was assigned to Resident #2 revealed she had just finished changing the resident because she had had a bowel movement and asked Nurse [NAME] to assist her with moving the resident from the bed to the reclining Geri-Chair using the Hoyer lift. The resident was clean and well groomed. It was observed that there was a camera in his room by his bed next to the divider curtain. CNA G said the resident was only oriented to person, he occasionally said a word or two, followed simple commands, was up in the Geri-chair as tolerated, ate his meals in the dining room, required total care, incontinent of bowel & bladder. She said the resident was checked every two hours and as needed to check if he was incontinent. She said, I need to check him more often for incontinence, because the nurses give him a medication that causes him to have loose stools. She said the resident's family member visited daily and would feed him his lunch meal. She said the resident would be put back to bed after meals. She said that residents were frequently found soaking wet at the start of shift. She said it usually happened when new CNAs are working. She said they had a high turnover of CNAs. She said she had reported this to the Nurses, and nothing was done to address this concern. She said, All they said is, OK then go change the residents. The CNA was observed taking the resident to the TV lounge at 11:26 a.m., after the interview was completed.During an interview on 06/03/26 at 12:33 p.m., a Family Member stated the facility was occasionally short of staff. The Family member said Resident #2 had been at the facility for over a year. The Family member said initially she would frequently find the resident soaking wet with urine. The Family member said the facility had a high turnover of staff and the new staff did not know resident's needs. The Family member said that she visited the resident every day and usually came to feed him lunch and stayed until the staff put him back to bed. The Family member said staff did not have time to check on the resident on a regular basis because there were days when the facility was short on staff and he was left wet for long periods of time. The Family member said that she had voiced her concerns during a care plan conference, and she did not know what the facility was doing to make sure that her brother was not left wet for long periods of times. During an observation and interview on 06/03/26 at 3:13 p.m., CNA D said she checked Resident #2 every two hours for incontinence. She said she needed to get help to change the resident's brief. It was observed that the resident did not assist with turning and repositioning in bed. The disposable brief was wet with fresh urine. The CNA cleaned the resident's buttocks with wipes. The resident's bed sheets were clean and dry. During an interview on 06/03/26 at 9:05 a.m., the Administrator stated he had started working at the facility on 05/11/26. He said the DON had started working at the facility in April 2026. He said that he was not aware of any concern reported by residents and/or families related to shortage of staff, leaving residents wet for long periods of time, or recurrent UTIs.During an interview on 06/04/26 at 10:27 a.m., LVN MDS Nurse E revealed the resident's Family Member and PASRR Case Worker had attended the care plan conference on 04/09/26 and had reported that Resident #2 was always found soaking wet with urine when she came to visit. The family member also said that the resident needed assistance to drink water. The family member said the resident was getting a lot of UTIs due to not getting enough water. She said the Family Member said she had reported this to the DON after the care plan conference. The MDS nurse said the resident could not use his call light for assistance and she did not know if the resident needed assistance to drink water. She said the resident should be checked every two hours for incontinence and as needed. She said that the PASRR Caseworker had stated at the meeting that the facility needed more staff. She said that they had a high turnover of staff and currently had sufficient CNAs. She said the resident had received IV fluids and was treated for antibiotics for a UTI. She said the family member had voiced concerns during the care plan conference about dehydration and UTIs.During an observation on 06/04/26 at 11:39 a.m., it was observed there were two CNAs in the room preparing to get Resident #2 out to bed and sit him in the Geri-chair for lunch. The resident was lying in bed. The resident was awake, lying on his back, and did not respond when the CNAs talked to him. The bed sheets were clean and dry. The resident kept moving his legs and arms up and down. The CNA said they attached the call light to the pillowcase; however, the resident could not use the call light. The CNA said they were going to check the disposable brief to see if the resident needed to be changed prior to sitting him in the Geri-chair. It was observed that the under pad was clean and dry. The disposable brief had fresh urine and was not soaking wet. The resident did not have any skin irritation or skin rash on his private parts and/or buttocks.During an interview and record review on 06/04/26 at 1:31 p.m., Social Worker H stated she had attended the care plan conference for Resident #2 on 04/09/26 and had not completed a Grievance Form when the resident's family member and PASRR Caseworker had voiced concerns about resident being left wet for long periods of time and frequently found soaking wet with urine by the resident's responsible party family member, the resident not being offered water and having a recurrence of UTIs. She said that she did not know if the concerns had been addressed by the nursing staff. She said that anyone can complete the Grievance/Concern form and the form can be given to her and/or the nurses. She said Grievances were addressed by the Department Heads and each Department Head was responsible for calling the person who had filed the complaint with a resolution. She said the Grievance Forms were kept in a binder in her office.During an interview on 06/04/26 at 1:37 p.m., the Administrator and the DON stated that a Grievance Form should have been completed after the care plan conference on 04/09/26 when the Family member and the PASRR Caseworker had voiced concerns about Resident #2 being wet for long periods of time and frequently finding the resident soaking wet with urine, not giving the resident water, and having recurrent UTIs. He said that Grievances were assigned to the Department Head, and they needed to call the person who filed a Grievance/Concern with a resolution. The DON said they had in-serviced the nursing staff on hydration and peri care. The DON said, I was never given a Grievance Form regarding these concerns, so I did not follow up on these concerns. She said right now they had sufficient CNAs and currently had two nursing positions opened on the evening shift. She said the number of CNAs was adjusted according to the resident census. She said they had a high turnover of CNAs. During a confidential interview on an undisclosed date at an undisclosed time, it was revealed that this morning at the start of shift a Resident #2 had been found soaking wet and dried urine ring. It was reported that this had been reported to the DON today at approximately 7:30 a.m. It was reported that residents are frequently found soaking wet at the change of shift when they schedule new CNAs and they do not know the residents. She said that the nurses ignored the staff when these concerns were reported to the nurses and they would say, Ok go and change the resident. It was reported that there was a high turnover of CNAs and sometimes they were short of staff so rounds could not be made every two hours, rushing to provide care and at times showers were not given as ordered.During an interview on 06/04/26 at 2:34 p.m., the DON in the presence of the Administrator, stated that one of the CNAs had reported to her this morning Resident #2 was found wet at the start of shift. She said she went to check the resident; however, the resident was already up and was sitting in the Geri-chair. She said the sheets were wet and did not have a dried urine ring. The DON said, I was going to do a counseling. Review of the facility's Grievance and Complaints Policy and Procedure Revised 08/2020 provided by the Administrator revealed, Purpose: To ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints. Policy: The facility advises residents and their representatives (including family, legal representatives and advocates) of their rights to file grievances without discrimination or reprisal and other process for finding grievances or complaints. The facility notifies residents of the rights to receive information from agencies acting as client advocates and provides information on how to contact these agencies. The facility ensures that there is no retaliation for filing a grievance or a complaint and ensures that there is a prompt review, investigation and response to and resolution of grievances and complaints. The disposition of all resident grievances and/or complaints is recorded in the facility's Resident Grievance/Complaint log. Procedure: Upon admission, residents or their representatives are provided with written information on how to file a grievance or complaint including the right to file grievances anonymously. Upon request, the facility will give a copy of the grievance policy to the resident. Any resident, representative, family member, staff, visitor, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, theft of property, etc., without fear of threat or reprisal in any form. Grievances and/or complaints may be submitted orally or in writing and can be made anonymously through the Compliance Hotline. Individuals will use Facility complaint forms or may use Resident Grievance complaint Form to submit written grievance reports. Designation of Grievance Official: The facility will identify a Grievance Official who is responsible for: Overseeing the grievance process; Receiving and tracking grievances through to their conclusion; Leading any necessary investigations by the facility; Issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary for specific allegations. Grievance Investigation: Upon receiving a resident grievance/complaint form, the Grievance Official or designee begins an investigation into the allegations. The Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged investigation is being investigated. The investigation and report includes, as applicable: The date and time the grievance was received; The date and time of alleged incident; The circumstances surrounding the alleged incident; The location of the alleged incident; Steps taken to investigate the grievance; The names of any witnesses and their accounts of the alleged incident; The residents account of the alleged incident; The employees account of the alleged incident; Accounts of any other individual involved (i.e., employee's supervisor, etc.); Summary of the pertinent findings, including whether the grievance was confirmed or not confirmed; Recommendations for corrective action; and Date the written grievance was issued. The Administrator will be provided with a complete Resident Grievance/Complaint Investigation Report within five (5) working days of the incident utilizing facilities specific forms. If follow-up is required, the Administrator is responsible for ensuring that the follow-up action is taken in a timely manner. The Facility will inform the resident or his or her representative or concerned party of the findings of the investigation and any corrective actions recommended in a timely manner. Grievance Complaint Log: The disposition of all written grievances and/or complaints is recorded on the Resident Grievance/Complaint Log. The Administrator or designee is responsible for recording and maintaining the log.

Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 12 residents (Residents #24, #25, and #68) reviewed for call lights. The facility failed to ensure resident call lights were within reach for Residents #24, #25, and #68 on 01/27/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.Findings included Resident #24 Record review of Resident #24's face-sheet dated 01/29/2026, revealed an [AGE] year-old female with initial admission date of 08/21/2025, and re-admission date of 12/27/2025. Record review of Resident #24's Health and Physical dated 08/27/2025, revealed a medical history of hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (weakness and paralysis following a stroke affecting the left non dominant side). Record review of Resident #24's admission MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Section GG-Functional Abilities notated Resident #24 needed partial/ moderate assistance, meaning the helper does more than half the effort to complete activities, for personal hygiene including shaving. Resident #24 was dependent meaning the helper does all the effort. Resident does none of the effort to complete the activity for toileting hygiene Record review of Resident #24's Care plan revised 01/12/2026, revealed Resident was at risk for falls related to a cerebral vascular accident (blockage of blood flow to a part of the brain). Interventions included ensuring the residents' call light was within reach and encouraging residents to use it for assistance. An observation on 01/27/2026 at 10:15 a.m., of Resident #24's call light on the floor under her bed. Resident was asleep in bed. Resident #25 Record review of Resident #25's admission Record dated 01/29/2026 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #25's Quarterly MDS dated [DATE] revealed Resident #25 under Section GG indicated the resident was dependent meaning the helper does all the effort for tasks of: toileting hygiene, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting, sit to stand, chair transfer, toilet and shower transfer. Under Section H, Resident #25 was coded for being frequently incontinent for urinary and bowel continence. Under Section C, Resident #25 had a BIMS of 15 indicating cognitively intact. Record review of Resident #25's care plan dated 12/01/2025 revealed Resident #25 had a focus of at risk for falls related to chairbound with assist and had an intervention of, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record review of Resident #25's physical and health dated 11/28/2025 revealed that Resident #25 was diagnosed with epilepsy (a seizure condition), chronic respiratory failure with hypoxia (a condition where the lungs cannot transfer oxygen into the blood), cognitive communication deficit, heart failure, myotonic dystrophy type 2 (a disorder causing muscle pain, stiffness, and weakness), pure motor hemiplegia (a stroke syndrome characterized by weakness of the face, arm, and leg on one side off the body), and end stage renal disease (kidney failure). An observation and interview made on 01/27/2026 at 11:20 AM, revealed Resident #25 requested assistance from surveyor to use the restroom and stated the call light was out of reach for him. It was observed that the call light was laid across the nightstand on the resident's left side when he was right side dominant due to his medical condition. A follow-up interview on 01/27/2026 at 12:52 PM, Resident #25 stated he was waiting for 20 minutes before surveyor's arrival and denied being affected physically or emotionally by the delay. He stated staff usually take 5 to 20 minutes to respond to call lights. Resident #68 Record review of Resident #68's face-sheet dated 01/29/2026, revealed a [AGE] year-old male with initial admission date of 10/25/2024, and re-admission date of 12/03/2025. Record review of Resident #68's Health and Physical dated 11/11/2025, revealed a medical history of muscle wasting and atrophy (decrease in size, mass and strength of muscle tissue). Record review of Resident #68's significant change MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Section GG Functional Abilities notated Resident #68 was dependent meaning the helper does all the effort to complete activities, for personal hygiene. Resident #68 was dependent meaning helper did all of the effort. Resident did none of the effort to complete the activity for toileting hygiene. Record review of Resident #68's Care plan revised 07/15/2025, revealed Resident was at risk for falls related to weakness, history of falls interventions included ensuring call light within reach. An observation and interview on 01/27/2026 at 9:55 a.m., Resident #68's call string was detached from the switch, Resident #68 stated he did not know where his call light was. In an interview conducted on 01/29/2026 at 11:43 AM, LVN C stated, a call light was used for staff to be notified that a resident needed assistance. LVN C denied receiving concerns from residents or family members regarding the call system in place with a string connected to a light switch that illuminated the call light outside the residents' room. LVN C added that the call system in place would not be functional for residents with a limited range of motion who would require a touch pad. LVN C stated there wasere no residents within his halls that had such a range of motion that required a touch pad call system. LVN C stated a resident who had their call light out of reach could be left thirsty, soiled, in pain, or injured until rounds and would not be able to notify staff. LVN C stated Resident #25 had successfully used the call light in the past and recognized the limited range of motion to the resident's left side. LVN C could not recall where the call light was located on 01/27/2026 at 11:20 AM when he was notified by a surveyor about Resident #25's needs. LVN C stated the call light should always be within reach for residents and placed on the resident's dominant side if there was lateral limitations. LVN C identified all staff was responsible for ensuring the call light was within reach for residents and was permitted to reposition the call light if it was out of reach. LVN C added that the last in-service he had received for call lights was within the past month, December 2025 to January 2026. In an interview conducted on 01/29/2026 at 12:13 PM, CNA B stated, the call lights was used by residents to contact staff. She stated the call light needed to be within reach for residents at all times. She added that a resident with a limited range of motion needed their call light on their dominant side. She stated that every staff member was responsible for responding to call lights and repositioning the call light if it was out of reach for residents. She stated a call light out of reach affected the resident because they could be left uncomfortable, injured, or soiled. She stated that the last in-service she received for call lights was within the past month, December 2025 to January 2026. In an interview on 01/29/2026 at 3:37 PM, the DON revealed that the purpose of the call light was for the resident to call for assistance if needed. She stated that staff does frequent rounding to ensure that call lights are within reach. It was the responsibility of the CNAs and nurses to ensure that call lights were within reach. She stated that if call lights was not within reach or string was not attached to switch, then the resident would not be able to call for assistance and would not be attended to in a timely manner. She stated that call light in-services were done on a monthly basis. In an interview on 01/29/2026 at 4:26 PM, with facility Administrator revealed that the purpose of the call light was for the resident to call for help if they needed assistance. She stated that the nurses and CNAs round at least every 2 hours if not more to ensure that the call lights was within reach. She stated that department heads also conducted daily rounds to ensure everything was in place in residents' rooms. If call lights were not within reach, the resident could potentially fall if they were trying to reach it or get out of bed. She stated that an in-service was done on 01/28/25. Record review of facility's In-service Training Report dated 03/28/25, and 01/20/26, revealed all staff participated in continuing education for call lights, including answering call lights, re-directing to the correct department, and not turning call light off without addressing resident's concern. Review of the facility policy titled Communication Call System revised on October 24th 2022 read in part . Call cords will be placed within the residents reach in the residents room .

Based on observation, interview, and record review the facility failed to ensure the residents had the right to examine the results of the most recent survey of the facility and the facility failed to post in a place that is readily accessible area for the entire facility reviewed for required postings. The facility failed to ensure the annual survey results binder had a posted notice and was accessible for residents, family members, and staff on 01/29/2026 This failure placed residents, family members, and legal representatives of the residents at risk by limiting their right to examine the facility's survey results.Findings include:During the Resident Council interview conducted on 01/29/2026 at 10:33 AM with 10 alert and oriented residents, the group was unaware of their right to review the annual state inspection binder and was not aware where they could locate the binder. During an observation conducted on 01/29/2026 at 11:27 AM, a white unlabeled binder was in a basket mounted to the wall to the right of the facility entrance near a glass case and posterboard for employee rights. The binder was observed to be attached to the basket by a chain and was approximately 4 feet from the ground. The contents of the binder included the past annual survey results and previous investigations conducted.In an interview conducted on 01/29/2026 at 11:54 AM, LVN C stated the binder of annual survey results could be located with the receptionist in the front. He added that he was not aware of the exact location for the binder. He stated that while employed at the facility no resident had ever asked him for the results before. He stated that a resident or family member might not be able to make an informed decision if they did not have access to the binder or where to locate it. He stated the binder should be at eye level for residents who utilized wheelchairs to ensure accessibility. He was unable to recall whether he had ever received an in-service or training on locating the annual survey results binder.In an interview conducted on 01/29/2026 at 12:22 PM, CNA B who stated, the results for the annual survey could be located on the facility software called Kardex. She added that the supervisors of the nursing department would have the binder for the results of the annual survey. She declined to know what information was available in the annual survey results binder. She stated that it was important to know the location of the binder so that staff could provide the information to residents, family members and anyone asking for it. She stated it affected the residents because it was their right to have access to this information. She denied receiving in-services or training on locating the annual survey results binder.In an interview conducted on 01/29/2026 at 12:30 PM, the Receptionist stated she did not know what the annual survey results binder was. She stated she did not know who monitored, updated, or ensured its accessibility to residents. She stated that if a family member or resident was to ask her for the binder or information pertaining to the annual survey results, she would refer them to the DON or the Administrator to provide further information. She stated that it was important for the facility to have the annual survey results binder so residents and family members could feel at ease and know that the facility is up to date. She confirmed it was the residents' right to have access to the annual survey results. She stated she had never received training or in-service on locating the annual survey results binder or about the contents of the binder. In an interview conducted on 01/29/2026 at 3:05 PM, the Activities Staff stated she was not aware if residents had the right to review the annual survey results of the facility. She added no resident had ever asked her for the results of the annual survey. She stated she does not know where the binder for the annual survey results could be located or what the contents of the binder would include. She stated it was important for residents to have access to this information so that they were informed on how the facility was evaluated. She denied receiving any training on locating or providing the survey results binder to residents. She denied notifying residents during resident council about their right to the annual survey results. In an interview conducted on 01/29/2026 at 3:37 PM, the DON stated, no resident or family member had ever requested the annual survey results binder from her. She denied knowing the current location of the annual survey results binder and where the facility could be located. She added that the information could be located online through government portals and residents/family members could ask for assistance from the receptionist, ADON, DON, and Administrator to locate this information apart from the binder located in the facility. She stated it was important that the annual survey results binder was available to everyone because it provided insight into the facility based on surveyor findings. She identified it was a resident's right for them to have access to the annual survey results binder. She denied providing or receiving training to her employees on locating and providing the annual survey results binder. She identified the Administrator as the individual responsible for updating and placing the annual survey results binder in an accessible area. She added that all direct care staff members and heads of department should be informed on the location and importance of the contents of the binder.In an interview conducted on 01/29/2026 at 4:45 PM, the Administrator stated, the annual survey results was located in a white binder near the entrance of the facility and online at care.gov. She stated that every staff member and head of department should be informed on where to locate the annual survey results binder. She stated that no residents or family members had asked for the annual survey results binder before. She added that the binder contained surveyors' findings during the annual recertification process from the year and from investigations completed. She stated that everybody who was in the facility should always have access to the binder. She stated that it affected residents and family members because they could be looking for the information and would not be able to find it or know who to ask for help. She stated that the resident should have access to the annual survey results binder. She denied providing training to the staff or department heads for the annual survey results binder. She declined to have a policy in place for mandatory postings or in reference to the annual survey results binder. Record review of the facility's monthly Resident Council Minutes dated 12/16/2025 under Resident Rights Issues Reviewed read in part: Resident rights. Record review of a previous meeting dated 11/17/2025 under Resident Rights Issues Reviewed read in part: Resident rights. Record review of a previous meeting dated 10/06/2025 under Resident Rights Issues Reviewed read in part: Resident rights. Record review of a previous meeting dated 09/08/2025 under Resident Rights Issues Reviewed read in part: -The right to receive visitors, -The right to participate in activities, -The right to file complaints and grievances without fear of retaliation. Record review of a previous meeting dated 08/04/2025 under Resident Rights Issues Reviewed read in part: Reviewed.Free of abuse. Right to complain.

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of six residents (Resident# 24, and Resident #68) reviewed for ADL care.The facility failed to ensure Resident #24's face was clean and free of facial hair on 01/27/26.The facility failed to ensure Resident #68's fingernails was clean and free from debris on 01/27/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs. Findings included: Resident # 24Record review of Resident #24's face-sheet dated 01/29/2026, revealed an [AGE] year-old female with initial admission date of 08/21/2025, and re-admission date of 12/27/2025.Record review of Resident #24's Health and Physical dated 08/27/2025, revealed a medical history of hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (weakness and paralysis following a stroke affecting the left non dominant side). Record review of Resident #24's admission MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Section GG-Functional Abilities notated Resident #24 needed partial/ moderate assistance, meaning the helper does more than half the effort to complete activities, for personal hygiene including shaving.Record review of Resident #24's Care plan revised 03/12/2024, revealed Resident had an ADL Self Care Performance deficit related to limited mobility. The interventions noted Resident #24 required partial moderate assistance with personal hygiene. An observation and interview on 01/27/2026 at 10:15 a.m., Resident #24 was observed to have long white hair on her chin. She declined to answer the question regarding grooming. Resident # 68Record review of Resident #68's face-sheet dated 01/29/2026, revealed a [AGE] year-old male with initial admission date of 10/25/2024, and re-admission date of 12/03/2025.Record review of Resident #68's Health and Physical dated 11/11/2025, revealed a medical history of muscle wasting and atrophy (decrease in size, mass and strength of muscle tissue).Record review of Resident #68's significant change MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Section GG Functional Abilities notated Resident #68 was dependent meaning the helper does all the effort to complete activities, for personal hygiene. Record review of Resident #68's Care plan revised 07/15/2025, revealed resident had an ADL Self Care Performance deficit related to limited weakness. The interventions noted Resident #68 was dependent with personal hygiene. An observation and interview on 01/27/2026 at 9:55 a.m., Resident #68 was observed to have long fingernails on right and left hands. He stated that his nails had not been cut, and that he would like them to be trimmed. In an interview on 01/29/2026 at 1:26 p.m., CNA F revealed that residents were checked for trimming when they were showered. If a resident voiced wanting their nails trimmed, they would trim them right away if the residents were not diabetic., for diabetic residents, the nurse would be responsible for trimming them. She stated that the nurse and CNAs were responsible for ensuring that the residents was well groomed, this included nail trimming and shaving. She stated that residents with long fingernails was at risk of injuring themselves by scratching themselves and causing an infection. She stated that facial grooming was also provided upon shower or per resident preference. She stated that if a female resident had long facial hair, she might feel self-conscious about it. She stated that the last Inservice over ADLs was given about a month ago. In an interview on 01/29/2026 at 2:04 p.m., LVN G revealed that CNAs would let the nurses know when the resident had long nails and needed to be trimmed. He stated that it was the responsibility of the nurses and CNAs to ensure to offer nail trimmings to the residents. He stated that long nails could lead to potential injury. He stated that CNAs would be able to trim nails if residents were not diabetic. He stated that facial grooming was offered to residents, and it was performed based on their preference. He stated that a potential risk for a female resident with long facial hair would be a negative view of themselves affecting their self-esteem. He stated that there was an ADL training upon hire and did not recall a recent in-service. In an interview on 01/29/2026 at 3:37 p.m., the DON revealed nail trimming was offered at least once a week by CNAs or nurses. If the resident was diabetic, the nurses would trim the nails if not the CNAs were able to do it. Nails were trimmed as soon as they were noticed to be long, or the residents voiced wanting a nail trim. She stated that a common risk of injury would be a resident scratching themselves. She stated that it was the responsibility of the nurses, CNAs and department heads to ensure that the residents were well groomed. She stated that facial grooming was performed upon resident request or family could request to have the resident shaved as well. She stated that there was no risk to female resident having long facial hair because it could be resident preference. She stated there was an in-service regarding ADLs she could not recall the date. In an interview on 01/29/2026 at 4:26 p.m., the Administrator revealed that nails and facial hair was trimmed and shaved as soon as it was noticed and residents was okay with trimming and shaving. She stated that the risk of long nails was that residents could scratch themselves causing injury and females with long facial hair could feel embarrassed by it. She stated that nurses, CNAs and department heads was responsible for ensuring that residents was well groomed. She stated that she could not recall the date of the last in-service over ADLs but that it was done last year. Review of the facility policy titled Grooming Care of the Fingernails and Toe nails not dated read in part . Fingernails are trimmed by Certified Nursing Assistants except for the residents with the following condition, Diabetes or circulatory impairment of the hands, ingrown infected or painful nails, nails that are too hard, thick or difficult to cut easily note: a licensed nurse will trim those residents)

Based on observation, interview, and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional for 1 of 1 (activities staff) reviewed for staff qualifications. The facility failed to ensure the activities staff had completed State approved training to direct facility activities. This failure could place residents who participated in facility activities at risk of physiological, psychological, social, and spiritual harm by receiving services from unlicensed personnel. Findings include: It was observed during survey from 01/27/2026 to 01/29/2026 the Activities Staff facilitated multiple activities during the week to include organizing the resident council meeting for the surveyor. Observation on 01/29/2026 at 3:05 PM, the Activities Staff badge had the title Activities Director covered with a printed label that read Staff. During an interview conducted on 01/29/2026 at 3:30 PM, the Activities Staff stated she was the individual responsible for organizing and hosting activities for the residents. She added that she had worked on Saturday and Sunday before to provide activities because there was no one else to facilitate activities for the residents on weekends. She stated she was not the Activities Director because she had not completed her certification. She added that she was working on her certification to become the Activities Director since December 2025 and anticipated completion for March 2026. She stated that she was previously employed as a CNA for the past 5 years, and this was her first full-time job working in activities. She added her previous experience as a CNA required her to assist in activities when asked, but that was not her full-time responsibility. In an interview conducted on 01/29/2026 at 3:45 PM, the DON stated it was not okay for staff to be working without a professional license or certification when the position required it. She added it was important to possess licenses for staff because it signified that the employee had completed their competencies to perform their duties. She agreed it was a liability for employees who provided services they were not licensed to perform. She stated HR was responsible for performing license checks prior to hiring individuals for licensed positions. She added that it was not appropriate for employees to provide care/services without the supervision of a licensed individual in place. She stated that HR does annual checks for licenses. She stated it affected residents who received services from an unlicensed individual because the employee may not be able to perform the task. In an interview conducted on 01/29/2026 at 03:50 PM, the HR Manager stated the Activities Staff was hired on 10/29/2025. She identified that the Regional Director of Activities was the Director of Activities for the facility; she added the Regional Director of Activities was not in the building and was a traveling employee. She stated within the year she had worked at the facility, the Regional Director of Activities had never been in the facility to her knowledge. She stated that the Activities Staff did not have a license or certification in place and added that Activities Staff was actively working on her certification. She stated that the Activities Staff began her course in December 2025 and was expected to finish in March 2025. She denied being concerned with unlicensed personnel facilitating activities. She confirmed that the Activities Staff was hired to facilitate activities independently with oversight from the Administrator and the Regional Director of Activities. She added that the facility was using the license of the Regional Director of Activities for compliance. She stated the Activities Staff nametag said Director because the individual who created the badge (unknown) thought she was hired as the Director. She stated that it was not acceptable for unlicensed staff to provide services when their position required a license. She identified herself as the individual responsible for ensuring staff was licensed prior to hiring the position. She added if an individual did not have a license for the position they were applying for, she would not hire them. She clarified because the position was for Activities Staff, the license was not required. She added she was not involved in the supervising activities conducted by the Activities Staff; this was left between the Regional Director of Activities and the Administrator to oversee the operation of activities. She stated she did not know how it would affect residents if the person in charge of activities was unlicensed. In an interview conducted on 01/29/2026 at 4:50 PM, the Administrator stated the Activities Staff and the Regional Director of Activities oversaw the activities department; she added she had not met the Regional Director of Activities since she began in October 2025. She stated the Activities Staff and the Regional Director of Activities conducted virtual communication for oversight of the facilities activities; she was unaware of the frequency of the meetings between the two or the contents of discussion between the two. She recognized that the Activities Staff was unlicensed and independently facilitated the activities. She stated that the Activities Staff should have had their license upon hire for compliance. She identified herself and the HR Manager was responsible for hiring the Activities Staff to independently host activities as an unlicensed employee. She added that herself and the HR Manager was responsible for ensuring employees had active licenses before providing services. She agreed it was unethical for the facility to appoint an unlicensed individual to complete tasks that required a license. She stated it could affect residents if an employee was providing unlicensed services and added there could be issues of competency on the employee's behalf. Record review of the facility's Background Check Policy revised 02/2025, read in part: Policy (subtitle) .This policy sets for the Company's procedures for conducting pre-employment background checks or all staff positions .Background Check. Checking or verifying any or all parts of the candidate's employment, educational, criminal, or certification/license histories .Education History Check. Verifying that the candidate possesses the relevant educational credentials cited or listed in the candidate's application .Certification or Licensure History Check. Verifying, if required for the position, that the candidate possesses the certifications or licenses listed in the candidate's application, resume, or cover letter, including establishing the current status of the relevant licenses. This includes any professional certification or license required for the position .General Procedure (subtitle) . Candidate for all staff positions are subject to standard background checks of employment, education, criminal, or certification and licensing histories. Criteria for identifying a position as possibly requiring license, or other additional background checks include but are not limited to: Direct responsibility for the care, safety, and/or security of individuals .A requirement for a certificate, professional license, or accreditation . Authority, Interpretation and Amendment (subtitle) The Payroll and Human Resources Account Managers are responsible for enforcing this policy. The Department of Human Resources is responsible for the general administration and implementation of this policy. Record review of the facility's employee roster for company 40488 undated, revealed one employee under the Activities Department with the title of Activities Staff.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #12, Resident # 46 and #62) of 12 residents observed for oxygen management. 1.The facility failed to ensure Resident #12's nasal canula was maintained off the floor while oxygen was in use on 01/27/2026. 2. The facility failed to clean the oxygen concentrator air filter for Resident #46 while the oxygen was in use, concentrators was observed with air filters with dust, and lint collected on them on 1/27/2026.3. The facility failed to ensure Resident #62's suction tubing equipment was stored properly on 01/27/26. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: 1.Record review of Resident #12's admission Record, dated 01/29/2026, revealed a [AGE] year-old female with an initial admission date of 11/03/2021, and re-admission date of 01/06/2026.Record review of Resident #12's history and physical document, dated 12/17/2025, revealed Resident #12 had a diagnosis of Chronic hypoxic respiratory failure (Long term condition where the lungs cannot get enough oxygen into the blood).Record review of Resident # 12's admission MDS, dated [DATE], revealed there was no BIMS score as the resident did not participate. Section O special treatments procedures and programs indicated use of oxygen therapy.Record review of Resident #12's care plan, revised 01/04/2026, revealed Resident #12 had altered respiratory status related to respiratory failure. The interventions included in the care plan were to provide oxygen as ordered. 2 liters per minute via nasal cannula. May titrate up to 4 Liters per minute as needed.2. Record review of Resident #62's admission record, dated 01/29/26, revealed a [AGE] year-old male with initial admission date of 09/11/23, and re-admission date of 08/04/25.Record review of Resident #62's PPS MDS, dated [DATE], revealed the BIMS was not conducted because Resident #62 was not able to participate. Resident #62 was never/rarely understood. The MDS noted under Section K- Swallowing/Nutritional Status, Resident #62 had a feeding tube on admission and while a resident in the facility.Record review of Resident #62's health and physical, dated 12/24/25, revealed a medical history of: Amyotrophic lateral sclerosis (a nervous system disease that affects the nerve cells causing loss of muscle control), and Acute Respiratory Failure with hypoxia (occurs suddenly when the lungs fail to adequately oxygenate the blood or remove carbon dioxide).Record review of Resident #62's care plan, with last revision made on 12/29/2025, noted the resident was to be on oxygen therapy and provide respiratory care as directed.3. Record review of Resident #46's admission sheet dated 01/29/2026 revealed a [AGE] year-old male with admission date 10/10/2025.Record review of Resident #46's Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating resident was cognitively intact. Section I-Active Diagnoses included Respiratory Failure. Section O noted Resident #46 was on Oxygen Therapy while a resident in the facility.Record review of Resident #46's diagnosis list dated 01/27/25 revealed a medical history of: hypertension (high blood pressure), Cerebrovascular Accident (CVA, or stroke, when blood flow to the brain is disrupted potentially leading to brain damage), seizure disorder (a burst of electrical activity in the brain that can cause changes in movement, behavior, and level of consciousness, which can last from a few seconds to minutes), anxiety disorder (excessive and persistent worrying or fear which can affect everyday life tasks), and acute respiratory failure with hypoxia (the lungs cannot adequately exchange gases, leading to low oxygen levels).Record review of Resident #46's care plan last revised 01/14/2026, revealed resident was on oxygen therapy via Nasal Cannula (a medical device that provides supplemental oxygen through 2 prongs that are placed in the nostrils). In an observation on 01/27/2026 at 9:31 AM revealed Resident #12's nasal cannula on the floor while the resident slept and the oxygen concentrator was in use. In an observation on 01/27/2026 at 9:45 AM, revealed Resident #62 was in his room, sitting in a specialized recliner chair with his feet elevated. A [NAME] (a firm plastic suction tip with a large opening with a bulbous head and is designed to suction secretions out of the resident's mouth) was observed at bedside on the nightstand, open to air. Resident #62 was not able to answer questions. In an observation on 01/27/2026 at 09:57 AM, Resident #46's oxygen concentrator filter was observed dirty with dust, and lint, while in use. Resident #46 was unable to recall when the filter was last cleaned.In an interview on 01/29/2026 at 1:20 PM, CNA F stated CNA staff was to notify the nurse of observed dirty oxygen concentrator filters, and she stated nurses was responsible for maintaining and ensuring they were clean. She stated the possible risk of the concentrator filter being dirty included for the resident potentially becoming ill from the dirty filter. CNA F stated there was an in-service regarding the concentrator maintenance but was unable to recall when. CNA F revealed when a resident's nasal canula was on the floor, the nursing staff were to throw it away and they were to replace it with a new nasal canula, because the one on the floor was considered contaminated and the resident could get an infection. She stated CNAs conducted rounds every 2 hours, during those rounds they checked to see if nasal cannulas were stored properly when not in use along with ensuring nasal cannulas were off of the floor. She stated it was the responsibility of the CNAs and nurses to ensure nasal cannulas were stored properly when not in use or on the resident while the oxygen concentrator was in use.In an interview on 01/29/2026 at 1:50 PM, LVN G stated the oxygen concentrator filters was to be clean. He stated CNA's was responsible for monitoring and cleaning the residents' oxygen concentrator filters. He said the filter was to be monitored after nurses provide resident care or provided assistance during their rounds. He stated potential risks for residents using an oxygen concentrator with a dirty filter, was possible infection and illness. LVN G revealed nasal cannulas were supposed to be stored in a bag when not in use and kept off from the floor. He stated if the nasal canula was found on the floor, it would have to be changed out due to contamination and risk of infection to residents. He stated the charge nurses were responsible to ensure the nasal cannulas were stored properly while not in use or that it was placed in the residents' nostrils while in use. He stated the facility conducted Inservice about oxygen/ tubing storage upon hire and had not been with the company long enough to have participated in another Inservice. LVN G stated suction equipment should not be left open to air and exposed. He stated the assigned nurse who provided suctioning was responsible for storing the equipment properly after being used. He stated it should not be exposed, should be stored, and it was an infection control issue. The assigned nurse would be responsible, after every use, staff stored it or threw it away and got new tubing.In an interview on 01/29/2026 at 03:15 PM, the ADON, who is also Infection Preventionist for the facility, she stated all staff was able to clean resident oxygen concentrator filters and all staff was responsible for ensuring it was clean. She stated the potential risk to residents not having a clean oxygen concentrator filter included an infection control issue as it could potentially affect the residents' respiratory system since they breathe in the oxygen from the concentrator. The ADON, she stated residents who required more frequent suctioning were left suctioning equipment stored at residents' bedside. She stated the nurse who performed the suctioning was responsible for storing it back into its original packing or container. She stated the purpose of having the [NAME] suction stored in its' container was for infection control. She stated she was responsible for monitoring and identifying potential infection control hazards and re-educate staff as needed. She stated she rounded on the residents daily. She stated the last in-service for infection control was October or November 2025.In an interview on 01/29/2026 at 3:37 PM with DON revealed when staff found a resident nasal canula on the floor, they were supposed to dispose of the nasal canula due to infection control, obtain a new tubing, label it and place back onto the resident. She stated there would be no risk for the residents if their nasal canula were found on the floor. She stated it was everyone's responsibility to ensure nasal cannulas were placed in residents' nostrils during use and not on the floor. She could not recall the last Inservice done over oxygen tubing/ storage. The DON stated nursing staff were responsible for ensuring [NAME] suctioning equipment were stored properly and covered for infection control. She stated the nurse assigned to the resident was responsible for ensuring all equipment per policy. The DON was shown the picture of Resident #62's suctioning equipment on 01/27/2026, and she stated the equipment was considered dirty and needed to be replaced. She stated there was no real risk to Resident #62, because the resident did not need to be suctioned frequently. The DON stated nursing staff was responsible for cleaning or changing oxygen concentrator equipment such as cannulas or filter. She stated nursing staff completed this task every 7 days, on Wednesdays. She stated for residents under hospice, the hospice agency will assist with cleaning the oxygen concentrator filter. She stated there was no potential risks for residents to use oxygen concentrators with dirty filters.In an interview on 01/29/2026 at 4:23 PM, the Administrator stated all direct care staff was responsible for ensuring oxygen concentrators was clean. She stated nursing monitored the residents and was unsure how often staff check the oxygen concentrator filters. She stated the potential risk of not having a clean oxygen concentrator filter was that the resident becoming ill since a dirty filter would not be able to filter properly. She stated department supervisors check in on residents daily through Ambassador rounds, and included ensuring the oxygen concentrator filter was clean. The Administrator revealed if the nasal cannula was found on the floor by the CNA, they would report it to the nurse so the nurse could change it. A nasal canula that was on the floor needed to be disposed of because it had been exposed to contaminates and it was an infection control issue that could potentially cause residents to become ill. She stated it was the responsibility of all staff to check that nasal cannulas were not on the floor. She stated ambassador rounds were conducted daily every morning by department heads, and each department head was responsible for doing rounds and part of those rounds included ensuring nasal cannulas were not on the floor when in use or stored properly when not in use. She stated that she could not recall the date of the Inservice regarding oxygen tubing storage and disposal, but she stated the facility had conducted one. Record review of the facility's In-service Training Report dated 08/07/25, noted nursing staff participated with continuing education for Oxygen Administration. The document did not specify who was responsible for cleaning the oxygen concentrator filters. Record review of the facility's policy titled Oxygen Administration, Nursing Manual-Nursing Care, with revision date 06/2020, read in part: Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues. Under Policy, bullet III. Infection Control, read in part: All oxygen tubing. Humidifiers, masks, and cannulas used to deliver oxygen: i. Are for single use only. Ii. Will be changed weekly and when visibly soiled, or as indicated by state regulation.Record review of the facility's policy titled Infection Prevention and Control Program- Infection Control Manual, with revision date 10/24/2022, read in part: Purpose: to ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Under Policy, it noted The facility must establish an Infection Prevention and Control Program under which it- A. identifies, investigates, and prevents infections in the facility. Under Program and Procedures, and C. Duties and Responsibilities, included vi. Help monitor and assess the facility-wide environmental infection control practices.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Resident #3 and Resident #7) reviewed for food and nutrition services.1. The facility failed to ensure Resident #3 and Resident #7 received food, in their rooms, at an appetizing temperature.2. The facility failed to adhere to their policy for acceptable serving temperatures. These failures could place residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction. Findings include:Findings include: 1. Record review of Resident #3's face-sheet, dated 01/29/2026, revealed an [AGE] year-old female with an initial admission date 09/08/2023 and re-admission date 09/23/2025. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 13, which indicated moderate cognitive impairment. Record review of Resident #3's care plan, last revised 01/21/2026, noted the resident was at risk for malnutrition and nutritional problems as she required a mechanical and therapeutic modified diet and included for staff to educate residents and families of not following the recommended diet. Record review of Resident #3's health and physical, dated 01/06/2026, revealed a medical history of: dementia and type II Diabetes. 2. Record review of Resident #7's face sheet, dated 01/29/2026, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE].Record review of Resident #7's annual MDS dated [DATE], revealed under Section K, Resident #7 didn't have dietary restrictions or limitations due to swallowing . Section C documented Resident #7's BIMS score was a 10, which indicated for mild cognitive impairment. Record review of Resident #7 care plan, dated 01/19/2026, revealed the resident had a focus of potential for nutritional problems/malnourishment related to cognitive impairment and poor appetite. Resident #7's intervention to address the goal was to monitor for significant weight loss (3 lbs. in 1 week), provide, serve diet as ordered, monitor and record intake, and the registered dietician to evaluate and make diet change recommendations as needed. Record review of Resident #7's physical and history, dated 05/11/2025, revealed the resident had a urinary tract infection (a bacterial infection in the kidneys, bladder, and urethra) and was experiencing deliriums (acute disturbance in cognition and attention). In addition, Resident #7 had a history of experiencing paranoia (unjustified suspicion), delusions (fixed false beliefs despite clear contrary evidence), and hallucinations (false sensory perceptions that feel real). In an observation of the steam table conducted on 01/28/2026 at 11:45 AM, revealed [NAME] A collected the temperatures for 7 hot meals being served that day: pozole (Mexican soup with pork and hominy) at 172 F, rice 170 F, chicken noodle soup 180 F, cream of mushroom [ROOM NUMBER] F, puree pinto beans 167 F, puree flour tortillas 155 F, puree pozole 141 F. During observation of meal delivery to resident rooms on 01/28/2026 at 12:50 PM, the sample trays were initially not on the cart due to storage limitations; the sample trays arrived at the cart at 12:58 PM after space was made available. The sample trays arrived at the conference room at 1:08 PM and temperatures were recaptured by the Dietary Manager: pozole 139.4 F, rice 132.6 F, tres leches cake (Mexican desert made from various milks; cold served) 45.4 F, puree pozole 113.7 F, puree rice 123.6 F, puree pinto beans with tortilla 121.2 F, puree tres leches cake 60.6 F. The test trays were sampled by the survey team and revealed the food was cold but still maintained an appetizing flavors. In an interview on 01/27/2026 at 10:08 AM with Resident #3, she stated she was on a pureed diet and did not like how the food tasted and the food temperature was occasionally cold. She stated she would purchase her own meals from out of the facility, or have family bring her meals she enjoyed. In an interview conducted on 01/27/2026 at 1:21 PM with Resident #7, who stated she preferred to eat in her room for all meals. She stated her meals would arrive in her room cold, especially the eggs and sausage. She added if she did not like it or if it was too cold, she would request a substitute meal and staff would honor her request. Interview with the Dietician on 01/28/2026 at 10:28 AM, the State Surveyor requested sample trays for puree and regular diet. In an interview on 01/29/2026 at 9:10 AM, with [NAME] A who stated the temperature of the food on the steam table needed to be 140 F or higher because it prevented contamination; and for foods served cold the temperature had to be 40 F or less to prevent contamination. She stated all residents received food at 140 F no matter if they ate in their room or in the dining room. She added this was done to prevent contamination and food borne illnesses associated with food served below 140 F. She identified monitoring the food temperatures was dietary staff's responsibility and specifically the Dietary Manager was responsible for ensuring dietary staff completed this task. She stated the last in-service training she received was 5 months prior.In an interview on 01/29/2026 at 9:37 AM with the Dietary Manager who stated, hot foods held on the steam table should be at 165 F and cold folds should be 35 F or less. He added food needed to be held at these temperatures to ensure the meal was cooked and edible. He clarified food could turn bad if not held at the proper temperature, which would result in the residents becoming ill. He stated food should be served to residents at 140 F for all residents who ate in their room or in the dining room. He stated residents who received cold food could be affected and experience disappointment, decreased appetite, or ultimately influence their nutritional status. In reference to the food tray samples, he stated the temperatures measured were not acceptable in accordance with the facility policy. He stated the last in-service provided to staff regarding food temperatures was in December 2025; documentation provided reflected the in-service for food temperatures was in April 2025.In an interview on 01/29/2026 at 10:06 AM with the Dietician who stated, hot foods on the steam table needed to be held at 145 F or more and cold foods needed to be held at 40 F. She added food needed to be in their temperature ranges to prevent the growth of bacteria in food from the danger zone (range between 40 F-140 F). She stated if contaminated food was consumed by residents, they could be exposed to food hazards. She stated a resident could experience negative effects on the body; she was unable to further elaborate due to limitations on clinical knowledge. She identified the cooks were responsible for monitoring food temperatures, and the dietary manager was responsible for ensuring cooks were completing proper food temperature monitoring. She stated meals should be served to all residents at 140 F or higher. She stated residents could be affected by food temperatures resulting in them declining cold food; she declined to elaborate on physiological and psychological effects due to her limited knowledge of these areas.In an interview on 01/29/2026 at 4:35 PM with the Administrator who stated, residents should receive hot foods at 140 F or higher and cold foods at 40 F or lower to prevent the food from spoiling. She added residents could get sick from their stomachs if they consumed food that was in the danger zone (range between 40 F-140 F) for too long. She identified the Cooks and Dietary Manager were responsible for ensuring the residents received food at acceptable temperatures per facility policy. She stated food delivered at unacceptable temperature ranges could result in the food losing its taste and residents could decline their food. She stated the last in service provided for food temperature was in December 2025. She identified the Dietary Manager was responsible for overseeing food delivery operations and ensuring staff monitored the temperatures.Record review of the facility's policy, dated 1/1/2026, titled Food Temperatures read in part: Measuring Food Temperature (subtitle) . At starting of meal services Hot Food should be above 140 F and Cold food should be served below 40 F . Acceptable Serving Temperature (subtitle) . Meats, entrees greater than 140 F . potatoes, pasta greater than 140 F . pureed foods greater than 140 F . dessert less than 40 F . milk less than 40 F

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen in the facility. 1. The facility failed to ensure expired foods were properly disposed. 2, The facility failed to ensure foods in the freezer and in the dry storage area were properly sealed and stored. 3. The facility failed to ensure the plastic strip doors to the walk-in fridge was not draped on the metal shelf with multiple hotdog packages. 4. The facility failed to ensure the freezer was free of trash. 5. The facility failed to ensure 2 dented cans (tapioca and tomato sauce) were .not stored on the floor in the dry storage room. 6. The facility failed to ensure a gallon of soy sauce located in the dry storage room was free of dry drippings. 7. The facility failed to ensure staff were trained to capture temperatures of waters for the 3-sink-compartment 8. The facility failed to ensure cookware was properly rinsed and sanitized in adherence to professional standards for food service safety. These failures could place residents at risk of food-borne illnesses.Findings include: During observations on 01/27/2026 beginning at 8:48 AM in the facility kitchen, revealed expired tortillas, dated 1/26/2026, in the fridge. At 8:49 AM, a carton of liquid eggs was in the second fridge with the top of the carton opened. At 8:49 AM, a cardboard box of frozen sugar cookie dough located in the freezer was left opened by the insulated bag and the cardboard flaps. At 8:54 AM, expired cheese, dated 01/24/2026, was in the walk-in fridge on the floor behind a metal shelf. At 8:54 AM, the plastic strip doors to the walk-in fridge were draped on a metal shelf that was held 3 sealed packages of hot dogs. At 8:56 AM, an empty cardboard box was left in the freezer on a metal shelf. At 8:56 AM, a package of frozen biscuits had a large opening through the film, and the remaining biscuits were left exposed to the air in the walk-in freezer. At 8:57 AM, an expired package of sopapillas, dated 01/01/2026, was discovered between the wall and cardboard boxes in the walk-in freezer. At 8:59 AM, 1 dented can of tomato sauce and 1 dented can of tapioca were located on the floor behind a rolling table in the dry storage room. At 9:00 AM, a 5-gallon container of cooking oil without the cap was on the metal shelving in the dry storage room. At 9:00 AM, a gallon of soy sauce with dry drippings from the spout, down the body of the container, was on a metal shelf. Observation on 01/28/2026 at 9:14 AM with Dietary Aide E, revealed sink the water temperatures for the 3-sink compartment were not captured and the wash, rinse, and sanitize cycle was completed in 11.58 seconds; not allowing the cookware to sit in the rinse and sanitization solution for a minimum of 1 minute as per facility policy. Dietary Aide E tested the sanitization solution with chemical testing strips that revealed 150-400 parts per million levels of quaternary ammonium within the water; acceptable levels per facility policy. In an interview on 01/27/2026 at 3:47 PM, with the Dietician who stated she visited the facility once a week and completed monthly audits on the kitchen to include dining, sanitization, serving, test trays, steam table, labeling and storage of foods in the fridge, freezer and dry storage. She stated the last audit she completed was on 01/07/2026 which resulted in a score or 95%. She stated her expectations of the kitchen were for everything to be labelled with dates, no items on the floor, and for food to be covered and properly sealed. She clarified food not properly sealed could lead to cross contamination and result in food borne illness. She was provided photos of the open carton of eggs, biscuits, and sugar cookies, expired corn tortillas, cheese, and sopapillas, and dry storage room findings and stated the conditions and storage of these photos were not acceptable. She stated this could affect the residents by exposing them to cross-contaminated food which could result in a potential food borne illness. She added a resident could experience negative effects and could potentially require hospitalization from complications with food-borne illness. She stated the last in-service she provided to the kitchen was on 12/26/2025 and provided supporting documentation for record review. She stated everybody in the kitchen was responsible for upholding cleanliness, sanitization, and proper storage. She identified the Dietary Manager was responsible for ensuring the expectations of the kitchen were being met by dietary aides and cooks. In a follow-up interview with the Dietician on 01/29/2026 at 10:06 AM regarding the 3-sink compartment observation, she stated the purpose of the 3 sink was to clean and disinfect large cookware and serving utensils. She denied knowing what the temperature of the waters needed to be for the 3-sink compartment. She stated cookware needed to be left in the sanitizer (quaternary ammonium) for a minute or more to ensure all bacteria was killed. She clarified if this was not done the cookware could still contain contaminants. In an interview on 01/28/2026 at 9:20 AM with Dietary Aide E, who stated the last time he received training for washing dishes was approximately 2 years prior. He stated the water for the sinks needed to be changed when you started cleaning dishes from the next meal, when the water was noticeably dirty, or whenever you finished cleaning dishes. He denied knowing what the temperature of the water was supposed to be for the 3-sinks and recognized he forgot to capture the temperature before beginning the task. He stated it was important to know what the temperature of the water was supposed to be to ensure the dishes were cleaned properly. He stated he had to rinse the cookware with regular water because it would disrupt the concentration of the sanitizer if he didn't. He stated if cookware was not properly sanitized and used to hold/serve food, residents could become sick. He stated cookware did not need to be left soaking in the sanitizer solution it could be dunked and removed to dry immediately. He added that was how he was trained to complete the cookware washing task. In an interview on 01/28/2026 at 3:20 PM, with Dietary Aide D who stated the water temperature for the 3-sink compartment needed to be higher than 100 F. She stated the left sink contained soap and water, the middle sink was water, and the right sink was water with sanitizer. She stated cookware needed to be left in the sanitizer solution for 1 to 5 minutes to kill bacteria and prevent cross contamination. She added if cookware was not properly sanitized it could be contaminated and potentially affect the residents by exposing them to food-borne illness. She stated a resident could experience stomach sickness and vomit if they consumed cross-contaminated food. She stated she assisted with cleaning all fridges and freezers as this was a daily task. She stated expired food needed to be discarded because it could be mistakenly used and served to residents. She identified all dietary staff were responsible for discarding expired food and properly sealing food. She identified the Dietary Manager was responsible for ensuring staff were completing these tasks accordingly. She stated she received training for dishwashing in January 2025 and for proper food storage in November 2025. In an interview on 01/29/2026 at 9:10 AM, with [NAME] A who stated her responsibilities as a [NAME] were to clean the fridges, freezers, walk-ins and dry storage areas daily. She stated she discarded all ingredients that had expired because they had no use. She stated she also reviewed the food to ensure everything was properly sealed and covered. She stated this was a task all dietary staff completed throughout the day. She stated discarding expired food and properly sealing food needed to be done to prevent cross contamination and food-borne illness. She stated the plastic strip door was used to keep the cold from escaping the fridge. She added they needed to always be in front of the fridge door to prevent temperature from escaping. She stated the plastic strip door on the metal shelf was cross contamination because food encountered an object that was touched by employee's clothes and shoes. In reference to the 3-sink compartment, she stated the water temperature needed to be between 160 F to 200 F so cookware was properly washed, rinsed, and sanitized. She added cookware needed to be left in the sanitizing solution for more than a minute to thoroughly clean cookware. She stated the last in-service she received for food storage and 3-sink compartment was in August 2025. In an interview on 01/29/2026 at 9:37 AM, with the Dietary Manager who stated the observations made during the initial walk-through of the kitchen (expired food, unsealed food, plastic strip door, dry storage room findings) were not acceptable conditions. He added the conditions observed were potential for cross contamination because bacteria could have encountered food. He identified all dietary staff were responsible for properly sealing food, keeping the plastic strip doors down, and discarding expired food during their shift. He identified himself as the individual who was responsible for overseeing dietary staff was adhering to responsibilities and being completed per facility policy. He stated these conditions affected residents by potentially exposing them to cross contaminated food. In reference to the 3-sink compartment, he stated the left sink was for soap and water, the middle sink was for water, and the right sink was for sanitizer and water. He added the sanitizer, and water was used to kill any bacteria that might be leftover on the cookware. He stated the temperature for the left and middle sink needed to be 120 F or higher and the right sink needed to be cold due to the chemical solution for sanitizing. He stated staff should check water temperatures before beginning the dishwashing process. He added cookware needed to be soaked in the sanitizer solution for one minute to kill the remaining bacteria. He recognized this was not conducted during 3-sink compartment observations on 01/28/2026. He stated if cookware was not properly sanitized, it could lead to cross contamination and food-borne illnesses. He was unable to recall when the last in-service training was regarding 3-sink compartment and food storage. In an interview on 01/29/2026 at 4:35 PM, with the Administrator who stated the kitchen should be clean, organized, nothing on the floor, food should be sealed and dated, dented cans should be in a designated area, expired food should be discarded, and the plastic strip door should be in front of the door at all times. She identified dietary staff was responsible for completing all tasks necessary to maintain a sanitary kitchen. She identified the Dietary Manager was responsible for ensuring dietary staff completed responsibilities in adherence to facility policy and standards. She stated residents could be affected by improper food storage and sanitization practices by exposing residents to cross-contaminated food. She stated a resident who consumed cross-contaminated food could become sick. Record review of the facility's policy, revised 01/21/2025, titled Food Storage read in part: Frozen Meat/ Poultry and Food Guidelines (subtitle) . Foods to be frozen should be stored in airtight in the original packing containers or plastic Ziploc bags or wrapped in heavy duty aluminum foil or special laminated papers . Canned Fruit/Vegetable Storage Guidelines (subtitle) . Dented or bulging cans should be placed in separate storage areas and returned for credit or discarded . Dry Storage Guidelines (subtitle) . Foods should be stored off the floor. Any open products should be placed in storage containers with tight-fitting lids or plastic Ziploc storage bags . Record review of the facility's policy, revised 01/25/2025, titled Sanitizing Agents - Acceptable Levels and Testing Methods read in part: Acceptable Sanitizer Levels (subtitle). All items will be sanitized by one of the following methods .Immersion for a period of at least one minute in a chemical sanitizing solution containing: . At least 150-400 parts per million quaternary ammonium at a temperature of no less than 75 F

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 3 dumpsters (Dumpster #2) reviewed for food and nutrition services. The facility failed to ensure the dumpster was closed for 1 of 3 dumpsters, and the surrounding area was free of debris on 01/27/2026. This failure could place residents at risk to an infestation of rodents and insects. Findings include: During observation of the dumpsters on 01/27/2026 at 9:08 AM, revealed 1 of the 3 dumpsters was left opened by the overhead plastic lid. The surrounding area for the dumpster corral had approximately 15 wooden pallets, 1 plastic rolling trash bin, 1 fish tank, and various types of waste on the ground (food, gloves, plastic, over-the-counter medicine bottle, briefs, bed liners, cans, and leaves). In an interview conducted on 01/28/2026 at 3:32 PM, with Dietary Aide D who explained the process of disposing of waste in the dumpsters. She stated she would apply gloves, collect all the trash in the kitchen in the rolling plastic bins, close the lid during transport to the dumpsters, tie the bag, discard, and ensure the dumpster was closed after use. She stated it was not acceptable for debris to be left on the floor because it was cross contamination and would attract cockroaches, flies, mice and cats. She added there was potential for insects and animals to enter the facility if there was an infestation at the dumpster. She identified every staff member was responsible for closing the dumpster after use. She stated the trash should be free of debris at all time. She declined knowing whose responsibility it was to maintain and remove debris. In an interview on 01/29/2026 at 9:29 AM, with [NAME] A who stated she would usually discard the kitchen trash near the end of her shift. She noted the dumpster was dirty two days prior but it now was much cleaner and free of debris. She stated the previous condition of the trash was not acceptable because it attracted organisms, animals and insects. She added there was potential for cross contamination and could potentially affect the facility. She was unable to further elaborate on how it could affect the facility beyond cross contamination. She stated the dumpster needed to be closed at all times to prevent odors from escaping and from attracting animals and insects. She identified a woman and man who were responsible for maintaining the dumpsters but was unable to recall names or department. She stated whoever used the dumpster last was responsible for closing the dumpster after use. She stated the last in-service training she received for the dumpster was 5 months prior. In an interview on 01/29/2026 at 9:59 AM, with the Dietary Manager who stated the condition of dumpster on 01/27/2026 was not acceptable because it was left opened and there were debris on the ground around the dumpsters. He stated the importance of closing the dumpster was to prevent infestation of insects and animals. He stated an infestation could potentially migrate and cross contaminate the facility. He identified all employees were responsible for ensuring the dumpster was closed. He stated if anyone had a concern for the condition of the dumpsters, they could notify the Administrator. He provided documentation for an in-service attendance record titled, Trash and Dumpster Comp that was completed on 07/18/2025. In an interview on 01/29/2026 at 11:45 AM, with LVN C who stated nursing used the dumpsters outside the facility to dispose of facility waste. He stated staff was supposed to close the dumpsters after every use. He added this needed to be done because trash could potentially fall out or could attract insects and animals. He stated the area around the dumpster needed to be free of debris, as well as, this could result in an infestation. He added there was potential for cross contamination and infection control if the facility's dumpster was not clean. He could not recall receiving in-service or training on how to properly dispose of waste or refusal. In an interview on 01/29/2026 at 12:02 PM, with Housekeeping who explained she collected trash from the residents' rooms and transported the waste to the dumpster by utilizing a plastic receptacle with wheels. She stated the contents of the trash could be food, waste, incontinent supplies, paper, and more. She stated after proper disposal she closed the lid to the dumpster, otherwise ants, insects, and animals could gain access to the waste. She stated the area around the dumpster needed to be cleaned to prevent bugs from developing in the area. She stated there was potential for insects to come into the building, because the dumpster was not located far from the facility. She denied receiving in-service or training on how to properly dispose of waste or refusal. In an interview on 01/29/2026 at 1:48 PM, with the Maintenance Supervisor who stated the dumpsters were shared with the apartments next to the facility. He stated he conducted exterior checks around the facility every morning. He stated debris were not supposed to be around the dumpsters because it made it difficult for the trash collector to maneuver the truck. He stated it was also for cleanliness and prevention of animals and insects getting into the trash. He stated the condition of the dumpster was a shared responsibility amongst all staff and departments. He stated the dumpster needed to be closed when not in use for the same reasons. He clarified any employee who was concerned with the dumpster could report it to their immediate supervisor. He stated a dumpster left open or with debris around would not affect residents and was not a potential for cross contamination. He denied providing in-services or training to staff or departments on proper disposal practices. In an interview on 01/29/2026 at 4:30 PM, with the Administrator who stated the dumpster had to be closed and free of debris to prevent bugs and insects from getting into the trash can. She stated everybody in the facility used the dumpster. She stated every employee was responsible for closing the dumpster after use. She stated employees were expected to report debris around the trash can to maintenance for removal. She clarified the dumpster needed to be closed to prevent offensive smells and bugs from accessing the contents of the dumpster. She stated infestation could affect residents because there was potential for insects and animals to migrate to the facility. Record review of the facility's policy, dated 04/01/2025, titled Garbage Cans, Dumpsters and Grease Trap Use and Cleaning read in part: Outside Trash Dumpsters (subtitle) . outside trash dumpsters, doors and/or lids will be kept closed when not in use. Outside trash dumpsters surrounding areas will be free of litter and debris

Based on observation, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for four halls (100-hall, 200-hall, 300-hall, and day-living area) reviewed for environment.The facility failed to maintain intact ceiling tiles in the 100-, 200-, and 300-, halls, and the day-living area, located next to the resident halls, on 01/27/2026.The facility failed to maintain stain-free ceiling tiles in the hall leading to the main dining area on 01/27/2026.These failures could place residents at risk of an unsafe, unsanitary, and uncomfortable environment. Observation on 01/28/2026 at 10:30 AM of the facility's ceiling tiles revealed they had cracks, and were bent, in the 100-, 200-, and 300- halls, and the day-living area located next to the resident halls.An observation on 01/28/2026 at 10:50 AM, of the hall leading to the main resident dining area was observed with stained ceiling tiles.In an interview on 01/29/2026 at 12:24 PM with the Maintenance Supervisor, he stated there was no policy regarding the environment of the facility, including the ceiling tiles. This state surveyor showed the Maintenance Supervisor pictures of the ceiling tiles in the living area and halls; he stated those ceiling tiles needed to be replaced, because they were cracked or damaged. He stated he was responsible for making those corrections in the facility building. He stated he monitored the facility environment daily. He stated he was not aware of the damaged/stained ceiling tiles until today and would replace them. He stated staff were trained to report any environmental concerns to him so he could address them. He stated with the pictures provided; he did not think there would be a risk to residents, staff, or visitors, unless someone moved the ceiling tiles.In an interview on 01/29/2026 at 1:17 PM with CNA F, she stated staff were trained to notify the nurse and maintenance of any environmental concerns right away. She stated the Maintenance supervisor was observed rounding through the facility daily, which included addressing environmental concerns. She stated the possible risks of the cracked, bent, ceiling tiles could be the possibility of it breaking and falling, which could cause someone to be injured if standing under or near the affected ceiling tiles.In an interview on 01/29/2026 at 2:02 PM with LVN G, he stated staff were trained to report their concerns to nursing staff or maintenance. He stated all staff were expected to report concerns right away. He stated maintenance was responsible for addressing facility environment concerns. The State Surveyor showed LVN G pictures of the mentioned ceiling tiles, and he stated he would report them as a concern so it could be replaced and fixed. He stated the possible risks for residents, staff, or visitors, being under or near cracked, bent, stained, ceiling tiles, could pose a risk for injury if it broke and fell.In an interview on 01/29/2026 at 4:06 PM with the DON, she stated staff were responsible for notifying maintenance of environmental concerns. She stated the Maintenance Supervisor was responsible for monitoring and fixing any facility maintenance concerns. She stated all supervisors would also assess the environment for potential concerns during their Ambassador rounds, daily. She stated there were no risks to residents, staff, and visitors.Interview with the Administrator on 01/28/2026 at 8:50 AM, the Administrator stated there was no policy regarding the environment or the facility's ceiling tiles.Record review of the facility's resident Grievances for the last 6 months did not have any concerns regarding the ceiling tiles.On 01/28/2025 at 4:00 PM, this State Surveyor requested documentation for maintenance work orders relating to the ceiling tiles from the facility, and it was not provided by time of exit.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement quality of life for one resident (Resident #62) of eight residents who was reviewed for dignity.The facility failed to cover Resident #62's foley catheter with a privacy bag, while resident was out of bed on 01/27/26.This failure could place the residents at risk of poor self-esteem and decrease of self-worth. Findings include:Record review of Resident #62's admission record, dated 01/29/26, revealed a [AGE] year-old male with initial admission date of 09/11/23, and re-admission date of 08/04/25.Record review of Resident #62's PPS MDS dated [DATE] revealed that the BIMS was not conducted because Resident #62 was not able to participate as he is never/rarely understood. The MDS noted under Section H- Bladder and Bowel, that the resident was marked with an indwelling catheter (including suprapubic catheter which is a flexible tube inserted through the abdominal wall to drain urine from the bladder, often used when traditional urethral catheters are not suitable).Record review of Resident #62's health and physical dated 12/24/25, revealed a medical history of: ALS (Amyotrophic lateral sclerosis, a nervous system disease that affects the nerve cells causing loss of muscle control), dysphagia (difficulty swallowing) post status PEG tube (a soft, flexible tube that provides a means of delivering nutrition directly into the stomach), suprapubic catheter, anxiety (a constant and/or intense feeling of worry or nervousness that could affect the person's ability to do daily activities), and depression (persistent feelings of sadness or hopelessness that can cause loss of interest in activities a person enjoyed).An observation on 01/27/2026 at 09:45 AM, Resident #62 was in his room, sitting in a specialized recliner located next to his bed, with his feet elevated. There was a foley catheter hanging on the side of the resident's chair, with yellow urine exposed. Resident #62 was unable to answer this surveyor's questions.In an interview on 01/29/2026 at 1:21 PM, CNA F stated all staff was responsible for ensuring the privacy bags was on residents foley catheters. She stated that the purpose of providing privacy was for residents' right to privacy. She stated direct care staff, including nursing staff, was responsible for ensuring the privacy bag was on after any care was provided to that resident. She stated the risk of a resident not having a privacy bag was a dignity issue. CNA F stated the facility provided an in-service training regarding foley catheter care, including providing privacy bags, but she was unable to recall the date.In an interview on 01/29/2026 at 1:54 PM, LVN G stated residents should always have the privacy bag on their foley catheter. He stated all nursing staff was responsible for monitoring residents including making sure a privacy bag was covering a resident's foley catheter, and the assigned nurse was responsible for overseeing the resident overall. LVN G stated the possible risk of foley catheters not being covered included for the resident having their self-esteem negatively affected, and it was a dignity issue.In an interview on 01/29/2026 at 4:00 PM, with the DON, she stated the resident was expected to have a privacy covering a resident's foley catheter when the resident was out of their room. She stated that the purpose of the privacy covering was to maintain the resident's privacy and dignity. The DON stated it was also for maintaining the resident's self-esteem. She stated CNA's was responsible for ensuring the privacy bag was on, as they were trained to apply a privacy covering, and all nursing staff was responsible for monitoring their residents.In an interview on 01/29/2026 at 4:21 PM, the Administrator stated the privacy bags was to provide the resident privacy by not exposing their urine to other residents or others in the nursing home. She stated the resident was expected to have their foley catheter covered when they leave their room. The Administrator stated nursing staff was responsible for ensuring the privacy bags was on residents' foley catheters. She stated there was Ambassador rounds, meaning different department supervisors, conducted daily check ins with the residents, and identification of concerns or issues in resident rooms, to be addressed. She stated that included privacy bags being on catheter bags. She stated the potential risk of residents not having a privacy bag covering the foley catheters included the resident feeling embarrassed.Record review of the facility's In-Service Training Report dated 08/07/2025 revealed staff received continuing education for Catheter Care.Record review of the facility's policy titled Catheter-Care of, Nursing Manual- Nursing Care, with no date read in part, under Procedure: IV. The resident's privacy and dignity will be protected by placing the cover over the drainage bag when the resident is out of bed.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility was labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 10 residents (Resident #62) reviewed for enteral feedings.The facility failed to label Resident #62's enteral feeding on 01/27/26.This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings include:Record review of Resident #62's admission record, dated 01/29/26, revealed a [AGE] year-old male with an initial admission date of 09/11/23, and re-admission date of 08/04/25.Record review of Resident #62's Prospective Payment System MDS, dated [DATE], revealed the BIMS was not conducted because Resident #62 was not able to participate and was never/rarely understood. Section K- Swallowing/Nutritional Status, noted Resident #62 had a feeding tube on admission and while a resident in the facility.Record review of Resident #62's health and physical, dated 12/24/25, revealed a medical history of: Amyotrophic lateral sclerosis (a nervous system disease that affects the nerve cells causing loss of muscle control), dysphagia (difficulty swallowing) post status PEG tube (a soft, flexible tube that provides a means of delivering nutrition directly into the stomach), anxiety (a constant and/or intense feeling of worry or nervousness that could affect the person's ability to do daily activities), and depression (persistent feelings of sadness or hopelessness that can cause loss of interest in activities a person enjoyed).Record review of Resident #62's care plan, with last revision made on 12/29/2025, noted the resident had dysphagia (difficulty swallowing) and required a G-tube (gastric tube, a flexible tube inserted through the abdominal wall directly into the stomach allowing for the delivery of liquid nutrition, fluids, and medications without the need for swallowing). Resident #62's goal included for the resident to maintain adequate nutritional and hydration status.An observation on 01/27/2026 at 09:45 AM revealed Resident #62 was in his room, sitting in a specialized recliner located next to his bed, with his feet elevated. An enteral feeding was observed to be hung at the resident's bedside and actively pumping. The bag was observed half full with pale brown fluid. There was no label on the enteral feeding observed, including no date, or name of feeding.In an interview on 01/29/2026 at 1:22 PM with CNA F, she stated nurses were responsible for ensuring residents' enteral feedings were dated and labeled. She stated the purpose of labeling the enteral feeding was for all staff and others were aware of the date the enteral feeding was being provided to the resident. She stated the possible risk of not labeling enteral feedings included spoilage of feeding, which could cause illness.In an interview on 01/29/2026 at 1:58 PM with LVN G, he stated nursing staff was responsible for ensuring enteral feedings that were being used were labeled. He stated that the assigned nurse completing the task was responsible for labeling the feeding they administered to the resident. He stated labeling included the name of the resident, room number, rate and goal of feeding, and the type of formula being administered. He stated the potential risk for not labeling residents' enteral feeding included the resident becoming sick. LVN G stated enteral feedings were to be replaced every 24 hours to prevent bacteria from growing.In an interview on 01/29/2026 at 3:19 PM with the ADON, who was also the Infection Control nurse for the facility, she stated enteral feedings were only to be used and administered for 24 hours. She stated the nurse administering the enteral feeding was responsible for labeling the feeding. She stated as the ADON; she was responsible for monitoring and confirming enteral feedings were labeled per protocol, which she did daily. She stated the risk to residents for not following protocol was an infection control issue.In an interview on 01/29/2026 at 4:04 PM with the DON, she stated nursing staff, specifically the assigned nurse administering the enteral feeding, was responsible for labeling the feeding and the saline used to flush the feeding. She stated the purpose of labeling the enteral feeding was to ensure it was a fresh feeding and giving the resident a new feed. She stated there were Ambassador rounds, which included supervisors from different departments to check in with their assigned residents daily, which included checking the room for potential concerns. She stated there was no potential risk for staff not enteral feedings not being labeled.Record review of the facility's, 06/30/2025, enteral feeding program which included ensuring the Label on the feeding tube was complete and accurate, with nursing staff signing as acknowledgement to the continuing education.Record review of the facility's policy titled Tube Feeding, Operational Manual, Nutrition services did not include labeling of enteral feeding.Record review of the facility's policy titled Infection Prevention and Control Program- Infection Control Manual, with revision date 10/24/2022, read in part: Purpose: to ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Under Program and Procedures, and C. Duties and Responsibilities, included vi. Help monitor and assess the facility-wide environmental infection control practices.

Based on interviews and record review, the facility failed to have a discharge summary that included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment and/or therapy, and pertinent lab, radiology, consultation results and final summary of resident status at the time of discharge for three (Residents #1, #2, and #3) of three residents reviewed for discharge summaries. The facility failed to complete a concise discharge summary of the residents stay and course of treatment in the facility for Residents #1, #2, and #3. This failure could place residents at risk of not receiving continuation of care to reduce the risk of complications and adverse events during the resident's transition to a new setting. Findings included:1. Review of the admission Record dated 11/13/25 for Resident #1 revealed, admission date 06/10/25; discharge date [DATE]. Review of the History & Physical dated 06/12/25 for Resident #1 revealed, [AGE] year-old female status post (after) upper respiratory infection, ureteral stones (a kidney stone that has moved from the kidney into the ureter, which is the tube that carries urine from the kidney to the bladder), Obstructive uropathy (a condition where urine flow is blocked, causing urine to back up and potentially damage the kidneys), pyelonephritis (is a kidney infection) and Alzheimer's dementia (a progressive and irreversible brain condition where brain cells are damaged and die, leading to memory loss, difficulty with daily tasks, and changes in personality).Record review of the admission MDS assessment dated [DATE] for Resident #1 revealed, entry Date: 06/10/25. Resident #1 entered from short-term general hospital. BIMS Summary Score - 11 (cognition was moderately impaired). Active Diagnoses: Obstructive Uropathy (medical condition where a blockage in the urinary tract prevents urine from flowing out of the body, causing it to back up and potentially injure the kidneys), Non-Alzheimer's Dementia, acute pyelonephritis, Muscle wasting, muscle weakness, calculus of kidney (kidney stone). Stage 3 pressure ulcer (a deep wound that has gone through the full thickness of the skin and into the fatty layer of tissue underneath, like a deep crater). Anticoagulant. Oxygen continuous therapy. Speech/Occupational/Physical Therapy. Section Q: Participation in Assessment and Goal Setting: Resident and Family. Resident's Overall Goal: Discharge to community. Source of information: Resident. Is active discharge Planning already occurring for the resident to return to community? Yes. Has a referral been made to the Local Contact Agency (LCA)? No. Reason Referral to Local Contact Agency (LCA) not made. Referral not wanted. Review of the Care Plan for Resident #1 dated 06/11/25 revealed Resident #1 wished to discharge home. Approaches were to make arrangements with required community resources. Review of the Order Audit Report dated 11/13/25 for Resident #1 revealed, an order dated 06/26/25 for DC home with meds. Home Health for PT/OT eval, skilled nursing for medication management and treatment, home health aide to assist with ADLs. Follow-up with PCP. Review of the Transfer/Discharge Report dated 11/13/25 for Resident #1 revealed, Resident #1 was discharged home on [DATE] with Home Health Services. Review of the Social Services Progress Notes for Resident #1 written by the former Social Worker K revealed:08/08/25 Discharge Planning/Discharge. Resident will DC home with meds today. Discharging due to NOMNC from therapy department. Home Health for PT/OT, Nursing evaluation and home health aide. Resident's family member to provide transportation at 10 AM. Resident confirmed she does have a wheelchair and walker at home. Wound Care Services provider will continue to provide wound care upon discharge. Resident will follow up with PCP. No concerns at this time.Review of the undated Notice of Medicare Non-Coverage (NOMNC) revealed Medicare Coverage of Current Skilled Nursing Facility Services would end on 08/07/25. The NOMNC was signed by Resident #1 on 08/01/25 and stated, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.Review of the Discharge summary dated [DATE] for Resident #1 revealed, the form did not document if Influenza/Pneumovax were administered or declined. Under Discharge Summary, it stated patient completed all required exercises for skilled therapy. Disposition of Medications: documented See MARS. Prognosis was blank. Special Treatments/Procedures were blank. Summary of Course in Facility: patient completed all required exercises for skilled therapy. Medical (vital signs, labs, diagnostic, etc. were left blank. Follow-up and Discharge Medication (instructions to resident) were left blank. Cognitive Function: was left blank. Psychosocial: was left blank. Sensory & Physical Impairments: were left blank. Skin Condition at discharge: Intact. Dental Condition: was blank. Physician's Order for Immediate Care: See primary physician as soon as possible for continue medication regime. Status Upon Discharge comment was blank. The Discharge Summary was not signed by the physician. 2. Review of the admission Record dated 11/14/25 for Resident #2 revealed, admission date 07/28/25. discharge date [DATE]. Review of the History & Physical dated 07/30/25 for Resident #2 revealed, [AGE] year-old female with history of chronic urinary tract infection, hydronephrosis with ureteral calculus (one of the kidneys is swelling because a kidney stone got stuck in the tube (ureter) connecting it to the bladder, blocking urine flow) and weakness. The resident has mild cognitive impairment. Review of the PPS Scheduled Assessment for a Medicare Part A Stay 5-day dated 07/31/25 for Resident #2 revealed, Entry Date: 07/28/25. Entered from short-term general hospital. BIMS Summary Score - 13 (cognitively intact). Active Diagnoses: Obstructive Uropathy (medical condition where a blockage in the urinary tract prevents urine from flowing out of the body, causing it to back up and potentially injure the kidneys), Urinary Tract Infection (last 30 days), muscle wasting, muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination. Section Q: Participation in Assessment and Goal Setting: Resident and Family. Resident's Overall Goal: Discharge to community. Source of information: Resident. Is active discharge Planning already occurring for the resident to return to community? Yes. Has a referral been made to the Local Contact Agency (LCA)? No. Reason Referral to Local Contact Agency (LCA) not made. Referral not wanted. Review of the Care Plan for Resident #2 revealed, Date initiated: 7/28/25 Resident wishes to discharge home. Approaches: Will make arrangements with required community resources. Review of the Social Worker's Progress Notes for Resident #2 written by Social Worker K revealed:-08/05/25 for Resident #1 revealed, Discharge Planning/Discharge. On this day, this worker met with resident regarding her discharge. This worker informed that her insurance issued a Notice of Medicare Non-Coverage with LCD 08/07/25. This worker explained the appeal process. Resident signed NOMNC. Will continue to f/u as necessary.-08/01/25 This worker contacted resident regarding her discharge plan. Resident informed her that her IV antibiotic will end on 08/05/25. Resident stated she wishes to d/c on 08/05/25. Resident declined home health services. Resident stated she is independent and active and does not feel she needs home health services. No other concerns were voiced at this time. Will continue to f/u as necessary. Review of the undated Notice of Medicare Non-Coverage documented Medicare Coverage of your Current Skilled Nursing Facility Services Will End on 08/07/25. The NOMNC was signed by Resident #2 on 08/05/25 documented, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.Review of the Discharge summary dated [DATE] for Resident #2 revealed, the form did not document if Influenza/Pneumovax were administered or declined. Disposition of Medications: only documented See MARS. Prognosis was left blank. Special Treatments/Procedures were blank. Summary of Course in Facility: patient done with all treatment. Medical (vital signs, labs, diagnostic, etc. were left blank. Cognition Function was blank. Psychosocial was left blank. Follow-up and Discharge Medication (instructions to resident) were left blank. Cognitive Function: was left blank. Psychosocial: was left blank. Sensory & Physical Impairments: were left blank. Dental Condition: was left blank. Physician's Order for Immediate Care was blank. Status Upon Discharge was left blank. The Discharge Summary was not signed by the physician. 3. Review of the admission Record dated 11/13/25 for Resident #3 revealed, original admission date 07/29/23 and readmission date 08/28/25. discharge date was 09/16/2025. Review of the History & Physical dated 07/30/25 for Resident #3 revealed, [AGE] year-old female status post right total knee arthroplasty (surgery to replace the damaged surfaces of a knee joint with artificial parts made of metal and plastic) admitted for rehabilitation services. Abnormality in her gait secondary to surgery. Review of the admission MDS dated [DATE] for Resident #3 revealed, Entry Date: 08/28/25. Entered from short-term general hospital. BIMS Summary Score - 13 (cognitively intact). Active Diagnoses: right artificial knee joint, muscle wasting, muscle weakness, difficulty walking, unsteadiness on feet, muscle weakness generalized. Section Q: Participation in Assessment and Goal Setting: Resident. Resident's Overall Goal: Discharge to community. Source of information: Resident. Is active discharge Planning already occurring for the resident to return to community? Yes. Has a referral been made to the Local Contact Agency (LCA)? No. Reason Referral to Local Contact Agency (LCA) not made. Referral not wanted. Review of Care Plan for Resident #1 dated 08/29/25 revealed the resident's discharge plans to return home. An approach was to make arrangements with required community resources. Review of Social Worker Progress Notes for Resident #3 written by Social Worker K revealed:09/10/25 Discharge Planning discharge: Resident will DC home with meds on Friday. Discharge due to NOMNC from insurance. The Resident lives at home. Resident agreed to arrange her own transportation. Home Health for PT/OT, Nursing Evaluation and home health aide. Resident confirmed she does not need a manual wheelchair. Resident confirmed she does have an FWW at home. Resident agreed to f/u with PCP. No concerns at this time.Review of Orthopedic Surgeons prescription dated 09/15/25 for Resident #3 revealed, OK to discharge home tomorrow.Review of the undated Notice of Medicare Non-Coverage documented Medicare Coverage of your Current Skilled Nursing Facility Services Will End on 09/11/25. The NOMNC was signed by Resident #3 on 09/09/25 documented, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. Review of the Discharge summary dated [DATE] for Resident #3 revealed, the form did not document if Influenza/Pneumovax were administered or declined. Discharge Summary: Resident dc'd from facility. Status Upon Discharge was left blank. The Discharge Summary was not signed by the physician. An interview and record review with the DON and Medical Records Staff on 11/12/25 at 11:42 AM, revealed that Residents #1, #2, and #3 did not have Discharge Summaries in their electronic medical record. The Medical Records Staff stated that she was new and had a stack of documents in her office that needed to be scanned into the resident's clinical records. She said, let me bring the stack of papers to see if the Discharge Summaries are there. An interview on 11/13/25 at 11:29 AM, with LVN A, on the 6:00 AM- 2:00 PM shift assigned to Halls 100/200, revealed the Discharge Plan was started upon admission, and a Discharge Summary was completed at the time of discharge. He said, the Social Worker would notify the nurses of the projected discharge date , and the nurses will call the physician to get the discharge order. He said the Discharge Summary had a summary of the care and services, diagnoses, medications, and information regarding referrals for Home Health Services. He said the nurse who discharged the resident signed the Discharge Summary on the day of discharge. He said that he did not know if Discharge Summaries were signed by the resident's physician. An interview on 11/13/25 at 11:38 AM with LVN B, on the 6:00 AM- 2:00 PM shift assigned to Halls 200/300, revealed Discharge Plans were started upon resident's admission to the facility. He said the Discharge Summary was completed by the nurses at the time of discharge. He said the Discharge Summary had a summary of the care and services, and diagnoses. He said nurses called the physician to get the discharge order. He said the discharge summaries were electronically signed by the nurse, who completed the form, and had to be signed by the physician. An interview on 11/14/25 at 11:11 AM, with the Director of Nurses and ADON RN D, revealed the Discharge Summary was completed at the time of discharge. She said the Discharge Summary included a summary of the care and services, diagnosis, and any referral information, such as Home Health Services. She said the Discharge Summary was signed by the Physician after the resident was discharged from the facility. During an interview and record review at 11:45 AM, with the Director of Nurses and ADON RN D, revealed the Recapitulation of Stay Resident Discharge summary dated [DATE] for Resident #1 did not document if Influenza/Pneumovax vaccines were administered or declined; Discharge Summary patient completed all required exercises for skilled therapy; Disposition of Medications See MARS. Prognosis was blank. Special Treatments/Procedures were left blank; Summary of Course in Facility was left blank; Medical (vital signs, labs, diagnostic, etc. was blank; Follow-up and Discharge Medication (instructions to resident) was left blank. Cognitive Function: was blank. Psychosocial: was blank. Sensory & Physical Impairments: was blank. Dental Condition: was blank. Status Upon Discharge was blank. The DON said the Discharge Summary still had not been signed by the physician. The DON said she was not aware Discharge Summaries needed to be signed by physician within twenty days after being notified by the facility of the discharge. The DON said the nursing staff had been trained on 09/03/25 on proper documentation in the resident electronic clinical record to ensure the documentation was complete. During an interview on 11/14/25 at 12:20 PM with Social Worker L revealed Discharge Plans were initiated upon admission, and the nurses completed the Discharge Summary on the day of discharge. During an interview on 11/14/25 at 1:35 PM with LVN ADON E revealed the nurses completed the Discharge Summary on the day of discharge. He said the Discharge Summary should include included a summary of the care and services, diagnosis, and any referral information such as Home Health Services.During an interview on 11/14/25 at 2:32 PM with RN H, assigned to Halls 200/300 on the evening shift, revealed the Discharge Summary was completed at the time of discharge. She said the Discharge Summary included a summary of the care and services, diagnosis, medications, therapy referrals, disposition of personal belongings, Durable Medical Equipment, referrals for Home Health Services, and resident education. Review of the facility's Transfer and Discharge Planning Policy and Procedures Operational Manual - admission and Discharge revised October 24, 2025, provided by the DON, revealed Purpose: To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe and appropriate discharge planning and necessary information. To the continuing care provider. Prior to discharging the resident, the facility will prepare a discharge summary and will document the summary and the residence medical record. At a minimum, the discharge summary will contain a summary of the resident status, including a description to the resident, medically defined conditions and prior medical history. Physical, mental, psychosocial functional status. The medical record will contain written documentation from the residence attending physician Related to reason for discharge.Review of the facility's Transfer and Discharge Planning Policy and Procedures Operational Manual - Social Services revised 02/2025 provided by the DON, revealed Purpose: To ensure that adequate Preparation and assistance is provided to residents prior to transfer or discharge from the facility. Documentation: A copy of the discharge summary will be provided to the resident and or the resident's family member upon discharge when return is not anticipated. The discharge summary will include the following information. Recapitulation of the resident stay, including, but not limited to, diagnosis, course of illness, treatment, pertinent labs, radiology and other consultation reports. A copy of the discharge summary and discharge care plan will be maintained in the residence medical record.

Based on interview and record review the facility failed to ensure a comprehensive person-centered care plan were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 of 6 residents (Resident #6) reviewed for care plans.The facility failed to invite hospice as part of the IDT team to help develop and implement a comprehensive person-centered care plan for Resident #6 who was on hospice.Findings include:Record review of Resident #6's face sheet dated 08/07/25, revealed, admission on [DATE] to the facility. Record review of Resident #6's hospital history and physical dated 03/31/25, revealed, a [AGE] year-old male diagnosed with Diabetes Mellitus and on hospice.Record review of Resident #6's quarterly MDS dated [DATE], revealed, a moderately impairment cognition BIMS of 12 to be able to recall or make daily decisions. Section O (Special Treatments, Procedures, and Programs) - was coded K1. Hospice Care. Record review of Resident #6's care plan dated 04/03/25, revealed, Resident #6 had a terminal prognosis and had elected to participate in hospice services. Consult with physicians and social services to have hospice care for resident in the facility.During an interview on 08/06/25 at 10:19 AM, with the family member, she stated the Hospice Team confirmed that the facility had not reached out to have the Hospice Team to be part of Resident #6's IDT team during his care plan meetings. The family member stated Hospice was finally invited for a care plan meeting that would be taking place sometime in September 2025, many months later after his admission [DATE]). During an interview on 08/06/25 at 10:22 AM, with the Ombudsman, he stated he was notified that by the family member Resident #6 had not had hospice be part of his care plan meeting(s). Ombudsman stated he was still looking into that situation to see what was going on.During an interview on 08/06/25 at 2:44 PM, with the Hospice Administrator, she stated hospice had to routinely ask the facility for information about Resident #6 so they could supply the facility with their hospice care plan for Resident #6 as they were not invited to the care plan meetings.During an interview on 08/06/25 at 4:37 PM, with Hospice Physician, he stated that it was very important that Hospice be at the care plan meetings as it was in the best interest for Resident #6 and the services that would be provided for care for him. The Hospice Physician stated that hospice always asks to sit with the facility to do the care plans but are never invited to the care plan meetings. The Hospice Physician stated hospice not being at the care plan meetings could have an affect the care of Resident #6 in which he might not receive the necessary care since he was on hospice.During an interview on 08/07/25 at 1:20 PM, with the Hospice SW, he stated hospice had not attended any actual care plan meetings for Resident #6. The Hospice SW stated the hospice was not part of the IDT nor were they invited to Resident #6's care plan meetings at the facility. The Hospice SW stated the family members wanted hospice to be part of the care plan meetings for Resident #6 and did not know why the facility was not having hospice as part of Resident #6's care plan. The Hospice SW stated it would be important for hospice to be present in the care plan meeting to discuss the services that would be provided to Resident #6. The Hospice SW stated not having hospice present could have services being missed for Resident #6.During an interview on 08/07/25 at 1:34 PM, with the Hospice Case Manager, he stated hospice had been invited to the care plan meeting in September 2025 but before that they had not been invited to any care plan meetings for Resident #6. The Hospice Case Manager stated they had been communicating with the DON and family regarding the review of the care plan and hospice does their own care plan for Resident #6. The Hospice Case Manager stated in the contract with the facility it stated in the delineation of duties that they have to be part of the IDT meetings which would be conducted by the physician, SW, RN, and spiritual care. The Hospice Case Manager stated the facility had a care plan for Resident #6 and it should have been correlating with the one that hospice had. The Hospice Case Manager stated any changes or deviations had to be reported to hospice so it would be updated in the hospice care plan.During an interview on 08/07/25 at 3:52 PM, with the Administrator, she stated the was SW was responsible and would be able to answer if residents who were on hospice had hospice invited to their care plan meetings. The Administrator stated as per facility policy hospice should have been invited to the care plan meeting(s). The Administrator stated the purpose of a care plan was to ensure that all the issues were addressed with all parts of care for the resident. The Administrator stated the care plan was a customized to meet the needs of each resident. The Administrator stated the negative outcome would be an area in care or services in the care plan being missed.During an interview on 08/18/25 at 1:13 PM, with the ADON, she stated the purpose of a care plan was to inform all departments and answer any questions someone may have regarding the resident. The ADON stated it was also the services being provided and what kind for the resident. The ADON stated the purpose of an IDT was also to inform of any changes or information related to the care of the resident. The ADON stated hospice should be invited as well so that all the IDT can be on the same page with care for the resident. The ADON stated hospice had not been present to any care plan meetings and did not know the reason why. The ADON stated the negative outcome of hospice not attending could be confusion on the general plan of care.During an interview on 08/18/25 at 2:35 PM, with the DON, she stated the purpose of a care plan was for family and everyone to know everything that was happening with the resident which addressed any concerns or issues and how to provide care for that resident. The DON stated the IDT was made up of the SW, dietary, nursing, therapy, activities, family members, and other pertinent parties. The DON stated the purpose of the IDT was to discuss everything and get a better understanding of the resident's needs. The DON stated hospice was not part of the care plan meetings and now they are. The DON stated as per facility policy hospice should have been invited to the care plan meetings for Resident #6. The DON stated there was no negative outcome as the facility always communicated with hospice about Resident #6.Record review of the facility Care Planning Policy dated 10/24/22, revealed, Purpose- To ensure that a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. Policy - The Care Plan serves as a course of action where the resident, resident's attending physician, and IDT work to help the resident move towards resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs. -Procedure- Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Any services that would be required. -The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following: Consultants (as Appropriate) and other individuals as appropriate or necessary.Record review of the facility Care and Services Policy dated 06/2020, revealed, Purpose- To ensure through an interdisciplinary team process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Policy- Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances qualify of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. -Procedure- The IDT receives and review initial assessment information to ensure that members of the IDT interact with the residents in a manner that enhances self-esteem and self-worth, such as activities related bathing, grooming, dining, recreational and social opportunities.Record review of the facility End of Life Care Policy dated 08/2020, revealed, Purpose- To provide a process to assist the resident in fulfilling their spiritual, physical, and emotional needs, and to provide emotional support to families of residents with terminal illness. Policy- The facility will help residents maintain their dignity and provide comfort and security to residents in a caring environment. Coordination with Hospice - If hospice care was involved, the resident's care plan will reflect hospice interventions. Social Services Staff will coordinate with Hospice staff to ensure that the residents needs are communicated to the hospice. Social Services staff may include the hospice team in the resident's IDT conference.

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #7) of 4 residents reviewed for ADL care for dependent residents.The facility failed to ensure the Hospice CNA provided perineal care with professional standards to ensure Resident #7 was clean, free of contamination. This failure placed residents who were dependent on staff for ADL care at risk for inappropriate transmission-based precautions to be used.Findings include: Record review of Resident #7's face sheet dated 08/18/25, revealed, admission on [DATE] to the facility. Record review of Resident #7's facility history and physical dated 05/14/25, revealed, an [AGE] year-old female diagnosed with Alzheimer's dementia with aggression and failure to thrive (a syndrome characterized by weight loss, poor nutrition, decreased activity, and a decline in overall functional ability, often accompanied by symptoms like depression and cognitive impairment). Record review of Resident #7's quarterly MDS dated [DATE], revealed, severe cognition of impairment BIMS of 6 to be able to recall or make daily decisions. Functional abilities were supervision or touching assistance (staff provides verbal cues and or touching/steadying and or contact guard assistance) with toileting. Resident #7 was always incontinent was urinary continence. Record review of Resident #7's care plan dated 05/14/25, revealed, had bladder incontinence related to activity intolerance. Monitor and document intake and output as per facility policy. Monitor fluid intake to determine if natural diuretics such as coffee, tea, or cola was contributing to increased urination and incontinence. Had terminal prognosis and under hospice's services related to atrial fibrillation. Consult with physician and social services to have hospice care for resident in the facility. Resident #7's ADLs was incontinent of bowel and bladder and required staff assist for cleansing and clothing. Observation on 08/07/25 at 6:11 AM, with Hospice CNA, revealed, perineal care was going to be provided to Resident #7 in her room. Hospice CNA entered the room and put on gloves and prepared the supplies to change Resident #7. Hospice CNA pulled several wipes from the package and placed them on top of the bed. Hospice CNA removed the soiled brief and disposed of it in the trashcan. Hospice CNA did not change gloves and did not perform hand hygiene. Hospice CNA proceeded to clean the resident's genital area with wipes from rectum to perineum (the area between the anus and vulva) and perineum to rectum. Hospice CNA cleaned buttock from front to back, it was observed that the wipes smeared with fecal matter, and she placed them on top of the clean wipes that were on the bed. that were on the bed. Hospice CNA disposed of dirty wipes in the trashcan and did not change gloves and did not perform hand hygiene. Hospice CNA put on the clean brief and continued to dress Resident #7. Hospice CNA was observed going through the drawers and closet with the contaminated gloves. Hospice CNA then proceeded to dress Resident #7, got her out of bed and sat her in the reclining Geri-chair. Hospice CNA then brushed Resident #7's hair. Hospice CNA then pulled the divider curtain with the contaminated gloves, put mousse on Resident #7's hair with the contaminated gloves, cleaned Resident #7's face and handed the resident a container of face cream so she could put cream on her face. During an interview on 08/07/25 at 6:35 AM, with the Hospice CNA, she stated she had been trained to clean the genital area from the top to the back and not go up and down with the same wipes to prevent contamination of the genital area. Hospice CNA said that she had been trained to change gloves and use hand sanitizer when she removed the soiled brief and dispose of the brief in the trash can. Hospice CNA said that she needed to change her gloves and use hand sanitizer each time that she removed the soiled gloves to prevent contamination by touching everything with the soiled gloves. Hospice CNA stated she had removed her gloves, entered the bathroom to wash her hands in the hand sink, and stated that the soap dispenser was empty. Hospice CNA stated she walked out of the bathroom and used hand sanitizer.During an interview on 08/18/25 at 10:25 AM, with the ADON, she stated when providing perineal care staff are to be washing their hands and putting on gloves. The ADON stated you start by cleaning the resident from front to back and make sure nothing gets soiled. The ADON stated then you throw away the soiled wipe and remove the gloves and clean your hands and reapply gloves. The ADON stated it would not be okay to be having dirty wipes on top of clean ones. The ADON stated not washing your hands and changing out your gloves could be a risk of infection. During an interview on 08/18/25 at 1:40 PM, with the DON, she stated she was the infection control preventionist. The DON stated when conducting perineal care, the staff had to wash their hands and talk to the resident letting them know what was going to happen. The DON stated all staff have to make sure they have their perineal care supplies ready. The DON stated you wash your hands and put on your gloves and open the brief and clean from front to back for females and males from the tip and down. The DON stated if there was any stool it would have to be cleaned first. The DON stated it was not okay to place dirty wipes on top of clean ones. The DON stated anything contaminated should not be touching anything else nor the same contaminated gloves should be touching anything. The DON stated gloves are to be replaced, thrown, and hand washing performed, and reapply new clean gloves. The DON stated it would be a risk of contamination. Record review of the facility Perineal Care Policy dated 06/2020, revealed, Purpose- To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Policy- Perineal care was provided as part of a resident's hygienic program, am minimum of once daily and per resident need. 1. Wash hands. 2. Explain procedure to resident. 3. Gather equipment. 4. Provide Privacy. 5. Put on gloves. 6. Wash the pubic area (the region on the lower abdomen, just above the genitals, where the pelvis meets at the front). - A. For a female resident(s): i. Separate the labia (the inner and outer folds of the vulva, at either side of the vagina). Wash the soapy washcloth/cleansing wipe, moving from front to back, on each side of the labia and in the center over the urethra (The tube through which urine leaves the body) and vaginal opening, using a clean washcloth/cleansing wipe for each stroke. ii. Rinse area, moving from front to back using a clean washcloth/cleansing wipe for each stroke. iii. Dry area moving from to back, using a blotting motion (gently dabbing or pressing an absorbent material onto a stain to soak up liquid without spreading it or damaging fibers) with towel. 7. Turn resident to side. 8. Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area (the region of the body located between the anus and the external genital organs). 9. Remove wet linen. 10. Place dry linens or briefs or both underneath resident. 11. Reposition resident. 12. Remove gloves. Wash hands or use alcohol-based hand sanitizer. Note: Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call bell, etc.) 13. Put on clean gloves. 14. Clean and return all equipment to tis proper place. 15. Place soiled linen in proper container. 16. Remove gloves. 17. Wash hands. Record review of the facility Infection Prevention and Control Program Policy dated 10/24/22, revealed, Purpose-The ensure the facility established and maintained an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements.

Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #8) of 4 residents reviewed for accidents hazards.The facility failed to provide safe transfer assistance, using proper transfer techniques for Resident #8. CNA A and CNA B failed to secure the brakes on the mechanical lift prior to lifting Resident #8 off the wheelchair.This failure placed the resident at risk of injury from improper transfer techniques.The findings included:Record review of Resident #8's face sheet dated 08/18/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #8's facility history and physical dated 06/05/25, revealed, a [AGE] year-old male diagnosed with dementia, degenerative disease of the central nervous system (a group of disorders where nerve cells in the brain and spinal cord progressively lose function, leading to a decline in physical and cognitive abilities), and Complete trisomy 21 syndrome (a genetic disorder where a person has a complete extra copy of chromosome 21 in all their cells, resulting from an error during the formation of egg or sperm). Record review of Resident #8's quarterly MDS dated [DATE], revealed, a BIMS was not taken to see the severity of impairment in cognition to be able to recall or make daily decision for Resident #8. It was not coded for mechanical lift. Functional abilities were dependent for roll left/right, sit to lying, lying to sitting on side bed, sit to stand, and chair/bed to chair transfer. Record review of Resident #8's care plan dated 05/17/25, revealed, ADLs self-care performance deficit related to down syndrome (a genetic condition where a person is born with an extra chromosome) and CVA (stroke occurs when a blood vessel in the brain becomes blocked or ruptures, cutting off blood flow to the brain). Transfer - extent/type may fluctuate within a day to day, depending on level of strength, pain, mood, etc. May require more staff assist or less. Resident was normally bedfast. Chair to bed dependent using 2 staff. On 08/06/25 at 8:30 AM a Facility Transfer, and ADLs Policy was requested from the Administrator and DON via e-mail but did not provide one of each by the facility. During an observation and interview on 08/06/25 at 10:27 AM, with CNA A and CNA B, revealed, Resident #8 was going to be transferred from his wheelchair to his bed. CNA B was heard providing instructions to Resident #8 of what was going to happen. CNA A was positioning the mechanical lift in between Resident #8's wheelchair while CNA B was ensuring the sling was placed appropriately underneath Resident #8. Once the mechanical lift was in position CNA A and CNA B began to hook up the sling to the mechanical lift. CNA A, without locking the mechanical lift brakes, began to lift Resident #8 into the air. CNA B moved the wheelchair and CNA A began to move Resident #8 over the bed and then began to lower Resident #8 down onto the bed. After the demonstration CNA A stated she had not locked the mechanical lift brakes. CNA B stated the mechanical lift brakes had to be locked or applied for the safety of Resident #8. CNA A stated not locking or applying the lift brakes could have resulted in injury to Resident #8. During an interview on 08/18/25 at 10:30 AM, with the ADON, she stated the DON/ADONs provide training on transfers to the staff. The ADON stated the mechanical lift brakes had to be applied when lifting a resident into the air for safety. The ADON stated staff should be ensuring the mechanical lift brakes are on before lifting a resident into the air. The ADON stated the risk could be injuries to the resident. During an interview on 08/18/25 at 1:40 PM, with the DON, she stated anytime a resident was going to be lifted into the air while using a mechanical lift the staff had to apply the mechanical lift brakes. The DON stated the negative impact of not applying the mechanical lift brakes could be the mechanical lift moving and possible injury to the resident. The DON stated the DON/ADONs were responsible for training staff on mechanical lifts.

Based on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 3 (Resident #7, #8, and #9) of 3 residents reviewed for accuracy of MDS assessment, in that: -The facility failed to ensure Residents #7's, #8's, and #9's MDS accurately reflected the residents' history of falls. This deficient practice could affect residents at the facility who had been assessed for risk of falls and could contribute to inadequate care. Findings included: Resident #7: Record review of Resident #7's Admission Record dated 03/19/2025, revealed an [AGE] year-old female was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unsteadiness on feet. Record review of Resident #7's MDS dated [DATE], revealed a BIMS of 06 indicating that the resident had severe cognitive impairment. Section I - Active Diagnoses revealed resident diagnosed with unsteadiness on feet. Section J - Health Conditions under fall history revealed that resident had not had any falls since admission or re-entry to the facility. Review of Resident #7's fall history revealed that Resident #7 had a fall on 01/27/2025. Record review of Resident #7's Care Plan dated 02/27/2025, reads in part on 1/27/25: Resident had an actual fall with injury related to dementia with behaviors, poor safety awareness, impulsive behaviors. Another part of the plan revealed that resident was at risk for falls related to gait/balance problems, dementia, history of falls, self-transferring, high risk medications, recurrent falls, and poor safety awareness. Resident #8: Record review of Resident #8's Admission Record dated 03/19/2025, revealed a [AGE] year-old female with an admitted [DATE]. Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), unsteadiness on feet, and history of falling. Record review of Resident #8's quarterly MDS dated [DATE], revealed a BIMS of 04 indicating that the resident had severe cognitive impairment. Section I - Active Diagnoses revealed resident diagnosed with unsteadiness on feet. Section J - Health Conditions under fall history revealed that resident had not had any falls since admission or re-entry to the facility. Review of Resident #8's fall history revealed that Resident #7 had a fall on 01/12/2025. Record review of Resident #8's Care Plan dated 02/27/2025, reads in part resident was found on the floor mat with no injury related to confusion and stated she was looking for her children. Another care area reads resident was at risk for falls related to weakness, anxiety, poor safety awareness, prefers to lie at the edge of the bed, confusion, nightmares, and history of recurring falls. Resident #9: Record review of Resident #9's Admission Record dated 03/19/2025, revealed an [AGE] year-old male with admitted [DATE]. Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unsteadiness on feet. Record review of Resident #9's quarterly MDS dated [DATE], revealed a BIMS of 12 indicating that the resident had moderate cognitive impairment. Section I - Active Diagnoses revealed resident diagnosed with unsteadiness on feet. Section J - Health Conditions under fall history revealed that resident had not had any falls since admission or re-entry to the facility. Review of Resident #9's fall history revealed that Resident #7 had a fall on 01/1/2025. Record review of Resident #9's Care Plan dated 02/27/2025, reads in part resident was at risk for falls related to CVA (cerebrovascular accident) weakness, left hemiparesis, history of falls, attempts to get out of bed. Another care area reads on 1/1/25 resident had an actual fall with minor injury of discoloration/abrasion/bruise to back of right hand. During an interview on 02/28/2025 at 1:04 p.m., the MDS Coordinator said an MDS covers everything about a resident's health conditions. The MDS Coordinator said it was very important for the MDS to be accurate as it was used to care plan. The MDS Coordinator said she was responsible to ensure that MDS was accurate and up to date. The MDS Coordinator reviewed Resident #7's, #8's, and #9's MDS's and said that the falls should have been captured on the assessments. The MDS Coordinator said the facility had undergone a change in ownership back in November 2024 and believes that she may not have had all the correct information when completing the MDS's for the residents. The MDS Coordinator said she should have followed up to ensure she had all the information she needed to complete the MDS . During an interview on 02/28/2025 at 3:15 p.m., the DON said the purpose of the MDS was assess resident in all care areas. The DON said it was very important for the MDS to be accurate as it may impact care planning for a resident. The DON said the MDS Coordinator was responsible for the MDS completion and accuracy. The DON said the MDS was done annually, quarterly, and when there was any change in condition including falls. The DON said the risk of falls not being captured accurately on the MDS may impact the interventions that were in place for the residents . Review of facility provided Fall Evaluation and Prevention policy dated 08/2020, reads in part The facility will evaluate residents for their fall risk and develop interventions for prevention. Review of RAI Version 3.0 manual dated October of 2019, reads in part regarding Section J fall assessment, the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment; Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls; Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury; Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record; Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment .

Based on interview, and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievances decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the resident's concerns; a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 of 4 (Resident #1) reviewed for resident rights. The facility failed to initiate and complete a grievance for Resident #1 who voiced a complaint of the facility response to cable service outage resulting in a delay to resolve the issue. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #1's face sheet dated 01/07/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's initial MDS assessment dated [DATE] revealed a BIMS score of 14 indicating she was cognitively intact. During a private interview on 01/07/2025 at 10:43 a.m., Resident #1 said the cable television channels went out the day before Christmas (12/24/2024), and there was only one channel available which was CSPAN. She said that she was admitted to the facility for recovery from knee surgery and watching the television was her preferred source of entertainment. Resident #1 said she complained immediately about the issue to staff and that the Maintenance Director attempted to do something to get more available channels but was not successful. Resident #1 said the facility activities staff offered her several things to do but she did not want any of those items. Resident #1 said the issue was not resolved until 01/06/2025. Resident #1 said when she was admitted to the facility, she was not informed of any facility grievance policy. Resident #1 said four days later, on 12/30/2024, she just talked to some lady at the facility who she thought was a boss at the facility. Resident #1 said she told the lady about her complaint. (Lady that was mentioned by Resident #1 was identified as the Facility Administrator). Resident #1 said no one explained to her how to file a grievance at the facility. Resident #1 said she was not provided any policy regarding the grievance process. Resident #1 said she was fine and was only inconvenienced by the issue. Resident #1 said the issue may have been resolved faster had an immediate grievance been filed. Review of Resident #1's admission packet revealed a blank grievance form. The document of policy Resident Grievance/Complaint Procedures was not part of the packet. During an interview on 01/07/2025 at 11:07 a.m., LVN C said the cable went out around Christmas time. LVN C said activities were provided to the residents who did not have other channels available. LVN C said Resident #1 was the person who complained about the cable not working. LVN C said she did not complete a written grievance form as the Maintenance Director was already aware and working on the issue. LVN C said she thought a grievance had already been filed. LVN C said if a resident had a grievance, the Grievance report forms are always located on a door file at the DON office and available. LVN C said she did not know if a grievance was filed for the issue. LVN C said the issue was not resolved until 01/06/2025. During an interview on 01/07/2025 at 1:15 p.m., the Maintenance Director said on Christmas day, the cable went out throughout the facility. He said due to a transition of new ownership, there was an issue with payment of services for the cable. The Maintenance Director said about 80% of the televisions in the facility were able to receive more channels by connecting to the internet. The Maintenance Director said Resident #1's television was one of the televisions that was not able to receive any other channels. The Maintenance Director said he was aware of the issue and attempted to rig the television to get more channels. The Maintenance Director said he did not file a grievance and only knew of the issue by visiting residents. The Maintenance Director said he did not know when administration learned of the issue. The Maintenance Director said the issue was resolved on 01/06/2025. Record review of the grievances for November 2024 through January 2025 revealed no grievance found for Resident #1's concern regarding the cable issue. During an interview on 01/07/2025 at 2:53 p.m., the Facility Administrator (FA) said she heard about the cable being out during a morning meeting on 12/27/2024. The FA said no formal written grievance was done. The FA said all grievances are forwarded to the Administrator to follow-up and address the issue until resolved. The FA said she was informed that the Maintenance Director would fix the issue. The FA said the activities department offered residents affected by the cable outage activities. The FA said on 12/30/2024, she learned that the issue was not resolved. The FA said Resident #1 was complaining about the issue and she went and spoke with the resident. The FA said she did not know that Resident #1 was only able to see one channel and not getting enough channels. The FA said she was told by Maintenance that it was a quick fix which did not turn out to be true. The FA said she did not complete a grievance for the issue and that a written grievance should have been completed. The FA said the facility grievance process broke down and she would have to take the hit for that one because there was no documented grievance and she believe she was given misinformation regarding the cable issue. The FA said if the process was followed, the issue may have been resolved sooner. The FA said there was no negative outcome to Resident #1, or any other residents affected by the cable outage. Record review of the facility provided Resident Grievance/Complaint Procedures, undated, reflected in part, A resident, representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members, theft of property, etc., without fear of threat or reprisal in any form. It is the policy of the facility to assist you in filing a grievance or complaint. Requested procedure to follow when filing a written grievance or complaint, obtain a Resident Grievance/Complaint Form from the nurse's station or from the Business Office; give the completed form to the Administrator or designee; after you have filed the grievance, you will receive a written summary of the results of the investigation within a reasonable time frame.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 (#1) kitchen reviewed for kitchen sanitation and food storage. 1. -The facility failed to keep the tile floors free of black grease build-up in the dry storage room. 2. -The facility failed to store foods in the dry storage room in sealed containers. 3. -The facility failed to keep food containers free of grease build up, and food particles in the dry storage room. 4. -The facility failed to keep the Sheet Pan Rack in the dry storage room free of stains, dust accumulation directly above the casters. 5. -The facility failed to store food cans separately from chemicals. 6. -The facility failed to keep one 5-gallon plastic water bottle off the floor. 7. -The facility failed to keep stainless steel sheet pans free food particles, black grease build-up and dried white stains. 8. -The facility failed to store food stored in the walk-in refrigerator in sealed containers. 9. -The facility failed to discard perishable foods stored in the walk-in refrigerator. Cucumbers were soft to touch, mushy, and had fuzzy white surfaces. 10. -The facility failed to keep food preparation tables and equipment free of rust, white stains, and food particles. 11. -The facility failed to keep foods stored in the refrigerator free of dried drippings. 12. -The facility failed to label and date foods stored in refrigerator. 13. -The facility failed to keep the metal shelving in the food preparation area free of dust. 14. -The facility failed to keep food containers and spice bottles completely sealed, free of dried drippings, residual on the sides of bottles, and grease build-up; and failed to ensure a scoop was not stored in a food container. 15. -The facility failed to keep the deep fryer free of rust and grease build-up. 16. -The facility failed to keep the food warmer free of dried white spots and control knobs free of dust, and grease build-up. 17. -The facility failed to keep the juice machine free of black substances. 18. -The facility failed to serve food at the appropriate temperatures. 19. -The facility failed to clean the food thermometer between foods when checking food temperatures. 20. -The facility failed to keep the kitchen walls free of dried water stains, black substances directly above the Food Warmer and, ceiling directly above by food preparation area. These failures could place residents at risk of food borne illnesses. Findings include: Observation and interview on 10/14/24 at 7:45 AM, with Dietary Manager during the initial tour in the kitchen, revealed the following: The Dry Storage Area revealed: An opened bag of Spaghetti wrapped in Saran wrap was not completely sealed; there were large ingredient storage bins that contained flour, rice, and thicker which had food particles and grease build up on the cover. The rice container had dried green vegetable leaves stuck on the left side of the cover. The Dietary Manager said staff were trained to place opened food packages in sealed Ziploc bags and to clean large ingredient storage bins daily. The Chemical Room revealed: dented food cans were stored on metal shelving in the chemical room next to a box of Bath Tissue Rolls and chemical bottles were stored on metal shelving. The Storage Area next to Serving line revealed: a 5-Gallon plastic water bottle was on the floor in front of the metal shelving where 5-Gallon plastic water bottles were stored. The Walk in Refrigerator revealed the following: -Stainless steel sheet pans where bags of food were stored had food particles, black grease build-up and dried white stains. -The sides of the stainless-steel mobile sheet pan rack had accumulation of food particles and dried white stains on the sides of the rack shelves that held the sheet pans. -Multiple metal storage pans stored in the refrigerator were covered with Saran wrap and were not fully sealed. -There was a large plastic container with cucumbers. Some to the cucumbers were soft, mushy and had fuzzy white surfaces. The plastic containers with red apples had dried white spots, food particles and vegetable leaves were on the cover. The Refrigerator revealed the following: -3-gallon container of classic sherbet stored on the bottom shelf was opened and was not date. The container had dried drippings on the side of the container and was placed on top of pieces of foil paper. The Dietary Manager demonstrated the container was leaking from the bottom and did not know why the container was not discarded. - A plastic container of sour cream had dried white stains on the cover. The Food Preparation Area by Stove revealed the following: -The Metal shelving was dusty. -There was one gallon of Worcestershire Sauce, 1 gallon of Vegetable/Olive oil, 1 gallon of Soy Sauce, 1 gallon of Less Sodium Soy Sauce, 1.32 gallon of Balsamic Vinegar, one 5 LB. plastic bottle of Honey, the bottles had dried stains and food residual on the covers and on the sides of the bottles. There was one 5 LB. plastic bottle of Ground Cinnamon, which had residual on the cover and sides of the bottle. -The Stainless steel table, where plastic food containers were stored, was rusted and had dried white stains. -The right side of the deep fryer was rusted and had grease build-up. -There was one 27 LB. plastic container that had powder residual and grease on the top and build-up on the sides of the container; one 20 LB. plastic container of Beef Base, cover was broken around the sides and had food particles and grease build-up; one 8 LB. plastic container of Chicken Flavored Base was opened and not covered. -The Food Warmer had grease build-up on the sides, food particles, the control knob was full of light gray lint, dust, and grease build-up. - The Large white countertop mixer had a dried white crusty white substance, dust, and grease build-up; and the countertop was full of dust and food particles. -A plastic container which contained kitchen tools had a cover full of dust and lint. -A one gallon plastic bottle of white pepper had grease build-up on the cover and residual on sides of the bottle; 3 gallon plastic bottles of Bay Leaves had grease build-up on the cover and residual on sides of the bottle; 1 gallon plastic bottle of Parley Flakes had grease build-up on the cover and residual on the sides of bottle; 1 gallon plastic bottle of Taco Mix had grease build-up on the cover and residual on the sides of the bottle; 1 gallon plastic bottle of onion powder, Thyme, Oregano, Chili Powder, Freeze Dried chopped chives, had grease build-up on the cover and residual on sides of the bottle; square plastic container with a green cover which contained Cilantro flakes, had food residual and grease build-up; a square plastic container with a green cover which contained thickener powder had a scoop in the container. Dietary Manager said staff should not store the scoop in the container. Two cans of cooking spray had grease build-up on the sides of the bottle. One 16-ounce box of Corn Starch was opened and was not sealed. The Dietary Manager said opened food containers should be stored in a sealed zip-lock bag and food containers should be cleaned by designated dietary staff once a month or as needed after each use. The Food Preparation Area by Food Warmer revealed: -44 plastic bottles of spices stored on metal shelves directly above the food preparation area had opened tops which were not sealed, there was residual on the tops and sides of bottles. The spice bottles were full of grease build-up. The wall directly above the Food Warmer, had multiple dark black substance. Observation and interview on 10/14/24 at 8:42 AM, of the serving line, with Dietary Manager revealed the Juice Machine had a black substance directly below the juice dispensers. Dietary Manager said the machine was cleaned weekly by designated dietary staff. Observation and interview on 10/14/24 at 8:43 AM, with Dietary Manager revealed a large, opened box of frozen biscuits was not sealed , in the walk-in freezer. Dietary Manager said dietary staff had been trained to store opened food containers in sealed containers or sealed plastic bags. In an interview on 10/14/24 at 1:00 PM, with Dietary Consultant revealed dietary staff had been trained to store foods in sealed and labeled containers; spice bottles should be kept sealed and cleaned after each use, dietary staff were all responsible for cleaning their designated areas daily and as needed. Environmental Check in Kitchen revealed: -there was extensive water damage to the ceiling, directly above the food preparation area by the stove and the ceiling in the Chemical room. The Dietary Manager said the ceiling in the kitchen and chemical room had been like that for several months, and they were trying to make the necessary repairs as soon as possible. There were dried light brown water stains on the wall and black substances on the walls directly above the Food Warmer. An Industrial Air Blower was directly above the exit door frame, had a screen cover full of dust and black grease build-up. The Dietary Manager said the maintenance staff were responsible for cleaning the Industrial Air Blower. Observation on 10/14/24 at 11:49 AM, the food temperature checks, with the Dietary Manager and [NAME] F revealed Spring rolls were 126 degrees Fahrenheit and were not re-heated prior to serving the lunch meal. The [NAME] did not clean the thermometer between foods when checking food temperatures . The Dietary Manager said the Cooks were trained to clean food thermometer with alcohol swab between foods to prevent food contamination. The [NAME] said she forgot to clean the thermometer between foods. Record review of the Food Code 2022 reflected the following: (C) Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. 3-202.15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Record Review of the facility's policy & procedure on General Sanitation - Food and Nutrition, revised 06/25/2024, reflected Purpose: To provide guidelines that limit the chance of foodborne illnesses at locations that prepare and/or serve food. Policy: The location stores, prepares, distributes, and serves food under sanitary conditions at all times. The location's food preparation, kitchen, serving areas and dry storage are cleaned and sanitized on a regular basis to limit contamination and prevent foodborne illnesses. Record review of the facility's policy & procedure on Food Supply Storage, revised 05/02/2024, reflected, Purpose: To ensure that food is stored properly. Policy: Food from approved food sources is stored in sanitary conditions and is not exposed to prolonged periods of excessive heat. Procedure: In the preparation and serving kitchen is obtained from approved food sources. Plastic bins may be used if preferred but must be in good repair and washed routinely. Stock items are individually dated with delivery date if removed from the original container. All food/supply items are stored 6 inches off the floor. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly. Chemicals are not stored near food items. Record review of the facility's policy & procedure on Food Temperature Monitoring, dated 12/21/2023, reflected, Purpose: To reinforce Hazard Analysis Critical Control Point (HACCP) guidelines and state and federal regulations regarding food temperature. Proper holding temperature - Temperature required for food safety (cold food <41 degrees Fahrenheit, hot food > 135 degrees Fahrenheit). Policy: Food is cooked, reheated or cooled to ensure proper holding temperature before each meal service. Food temperatures are taken and recorded before each meal service. Periodically, temperatures, are taken at other times during or at the end of meal service to ensure temperature are taken at other times during or at the end of meal service to ensure temperatures are held within acceptable ranges. Food is served at proper serving temperatures. Retake temperatures periodically throughout meal service to ensure TCS foods are held below 41 degrees Fahrenheit for cold foods or above 135 degrees Fahrenheit for hot foods. TCS hot foods should be served at 135 degrees Fahrenheit or higher. Hot foods are not heated in the steam table or temperature holding equipment. All foods are at appropriate temperatures prior to placing in serving equipment for hot holding. TCS cold foods will be held at or lower than 41 degrees Fahrenheit and served promptly after being removed from the refrigerator.

Based on interview and record review the facility failed to ensure resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #4) of 5 reviewed for transfers. On 11/30/22 CNA B transferred Resident #4 improperly and Resident #4 sustained a fracture to her clavicle. This failure resulted in actual harm to Resident #4 on 11/30/22. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents at risk for an accident and potential harm. Findings include: Review of Resident #4's face sheet dated 12/13/22 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Review of Resident #4's H&P dated 11/30/22 revealed diagnosis of unspecified macular degeneration, generalized muscle weakness, unspecified tremor, other abnormalities of gait and mobility. Review of Resident #4's care plan dated 11/28/22 revealed the resident has an ADL self-care performance deficit related to BLE muscle weakness; interventions SRHP - transfer between surfaces: total lift, large high back sling, X2 CNA assist. Review of Resident #4's MDS change in condition assessment was pending completion. Review of Resident #4's sit-stand-walk data collection admission assessment dated [DATE] revealed 4. Stand up- B. no, use total lift. Review of Resident #4's incident report dated 11/30/22 revealed incident report #2371; level of injury at time of investigation marked moderate; date of investigation 12/1/22; names of witnesses none; is this a repeat incident marked no; have there been previous injuries or circumstances of this type marked no; summarize factors that may have contributed to this incident- Resident #4 had recently returned from hospital and transfer status was changed total Hoyer lift, CNA used sit to stand machine for transfer; corrective actions taken to prevent recurrence of this incident- employee education/training, care plan amended, referral to orthopedic, other: self-report to state were marked; who will complete the above corrections: nursing staff; results of investigation- fracture to left clavicle, possible rotator cuff tear to right side, no bruising or swelling; narrative comments- resident lost leg strength during transfer leading to injuries, staff used wrong machine for transfer. Review of incident reports from August 2022- December 2022 revealed no other injuries related to transfer reported. Review of Resident #4's x-ray of left shoulder dated 11/30/22 revealed an acute and slightly displaced fracture of the distal clavicle. The acromioclavicular joint is not aligned at this point. Osteoporosis is seen. Sit up- 3. Can the resident move from a lying or reclining position to sitting on the edge of the bed was marked no, use of total lift when moving to a sitting position. Stand up- can the resident bear weight on at least one leg was marked no, use a total lift. Interview on 12/13/22 at 9:21 AM LVN A stated Resident #4 had returned from the hospital due to unrelated issues on 11/28/22; upon return she was downgraded to a total assist with Hoyer lift due to swelling to both legs. On 11/30/22, CNA B reported that while assisting Resident #4 on a sit to stand transfer, Resident #4 lost balance and dropped herself on to the wheelchair with all weight on her shoulder due to gait belt placement. LVN A stated she had administered Tylenol for pain at the time of the incident. Approximately 3-4 hours later, Resident #4 started complaining of more pain to her shoulder. LVN A stated she assessed Resident #4 and noticed swelling to her shoulder and Resident #4 had minimal movement, LVN A said she called the nurse practitioner, and received orders for Xray. LVN A stated Xray results revealed displacement of clavicle and Resident #4 was sent out for further evaluation. Interview on 12/13/22 at 9:51 AM CNA B stated Resident #4 had been out in the hospital for several days. CNA B stated she had worked with Resident #4 a few days after her return from the hospital but could not recall the date. CNA B stated the morning of the incident, she had tried to assist Resident #4 to use the restroom. CNA B stated she had used a sit to stand position transfer to assist Resident #4 off her wheelchair. CNA B stated when Resident #4 was at a standing position, she lost her balance and dropped back to a sitting position on her wheelchair. CNA B stated when Resident #4 dropped, she still had the gait belt under her arms and all her weight was placed on her shoulders. CNA B stated she assisted her to a sitting position and took off the gait belt. CNA B stated after the incident occurred, she was told by LVN A that Resident #4 was a Hoyer lift transfer. CNA B stated she failed to check the Kardex (care plan available for CNA's) prior to providing transfer assistance to Resident #4. CNA B stated she did not check the Kardex because she was familiar with Resident #4 in the past before the recent hospitalization . CNA B stated she had received training regarding transfers upon hire, annually and as needed. CNA B stated during those trainings she had been trained on the Kardex to verify the type of care they need and require. Interview on 12/13/22 at 4:37 PM the DON stated all nursing staff were trained regarding transfers and checking care plan and/or Kardex prior to providing care upon hire, annually and as needed. DON stated by not checking care plan/ Kardex prior to providing care i.e., a transfer, could result in an accident or injury. DON stated he spoke to CNA B after the incident who then stated she had forgotten to check and assumed there had not been a change in Resident #4 transfer. DON stated CNA B received counseling, one-to-one in-service, and check off competency. Review of Safe Resident Handling Program Overview policy dated 1/25/22 revealed the safe resident handling program enables caregivers to safely support residents who require partial or total assistance to ambulate, transfer and reposition. This program includes mobility and bathing equipment, program elements to support the use of equipment, employee training and a culture of safety approach to safety in the work environment. Mechanical lifting equipment and/or other approved residents handling aids must be used to prevent the manual lifting and handling of residents. Any deviation from the policies and procedures within the safe resident handling program in company policies located in inside company may result in corrective action up to and including termination. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Review of in-service (12/1/22): safe resident handling program policy, check for Kardex for any changes in transfers for new admissions, readmissions, or resident with a change in condition, care plan changes made to resident in room [Resident #4's room]. Review of safe resident handling equipment competency validation checklist for CNA B completed on 12/1/22. CNA B was the only employee who received competency training. Interview on 12/13/22 at 9:21 AM LVN A confirmed receiving training related to giving verbal report regarding any change in condition to CNA's, update care plans to reflect on Kardex on any changes for residents, and transfer change for Resident #4. Interview on 12/13/22 at 9:51 AM CNA B stated she received a one-to-one training and competency test. CNA B was able to correctly identify the process for checking Kardex prior to providing care and safety while providing transfer assistance. Interview on 12/13/22 at 2:41 PM CNA C confirmed receiving training related to giving verbal report regarding any change in condition to CNA's, update care plans to reflect on Kardex on any changes for residents, and transfer change for Resident #4. Interview on 12/13/22 at 2:50 PM LVN D confirmed receiving training related to giving verbal report regarding any change in condition to CNA's, update care plans to reflect on Kardex on any changes for residents, and transfer change for Resident #4. Interview on 12/13/22 at 3:12 PM LVN E confirmed receiving training related to giving verbal report regarding any change in condition to CNA's, update care plans to reflect on Kardex on any changes for residents, and transfer change for Resident #4. Interview on 12/13/22 at 4:37 PM the DON stated all nursing staff received in-service on 12/1/22 related to checking Kardex prior to providing care as well as changes in transfers techniques for Resident #4, prior to surveyor entering facility for investigation.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remains free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 7 residents reviewed for supervision to prevent accidents. The facility failed to ensure that Certified Nursing Assistant (CNA) A followed the MDS and facility care plan on mobility and transfers for Resident #1. This failure caused Resident #1 to sustain a fall that resulted in an acute femoral neck fracture. This failure could place residents at risk for injury. Findings include: Resident #1 Review of the Admission Record dated 09/14/20 for resident #1 revealed she was admitted on [DATE]. Record review of the History & Physical dated 12/18/2019 for resident #1 documented a [AGE] year-old female with diagnoses of CVA (Cerebrovascular Accident) with left sided [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], weakness, and organic mental disorder with behavioral issues. Record review of the Quarterly MDS, dated [DATE] for Resident #1 documented: clear speech, usually understood, and usually understands; BIMS score of 9 (moderate cognitive impairment); ADLs - total dependence with two person assist for bed mobility and transfers, total dependence with one person assist for dressing, personal hygiene and locomotion on/off unit, and extensive assistance with one person assist for eating and toilet use; impairment on one side to upper and lower extremities. Record review of care plan, dated 08/11/20 for Resident #1 documented: The resident has impaired cognitive function/dementia or impaired thought processes R/T late effects of CVA E/B poor decision making, short and long-term memory deficits, unaware of safety needs; The resident has limited physical mobility R/T S/P CVA E/B left [CONDITION(S)]/contractures, inability to perform transfers independently; The resident has an ADL self-care performance deficit R/T S/P CVA as evidenced by inability to perform ADLs independently, inability to self-administer medications, to include interventions of bed mobility - Lying to Sitting: total lift x2 assist with medium high back sling and transfer - Transfer Between Surfaces: total lift x2 assist with medium high back sling; The resident is at risk for falls R/T impaired mobility, weakness, unaware of safety needs, MS, [CONDITION(S)] disorders and medication side effects. Record review of hospital x-ray report, dated 09/05/20 for Resident #1 documented: XR Hip (L) fall with acute femoral fracture with moderate displacement. Record review of facility incident report, dated 09/05/20, documented the following statement from CNA A: CNA stated that she used the sit to stand to transfer resident from wheelchair to the bed. Resident was placed in bed and was in a sitting position, removed sling and moved device out of the way and noted her leaning as she was removing her pants, resident fell to her left side, she placed a pillow under her head and called the nurse. In an observation on 03/29/21 at 10:40AM, Resident #1 was observed to be lifted up from bed to be taken to therapy. Hoyer lift transfer was performed successfully, with no issues. Resident appeared to be well groomed and happy. In an attempt to interview Resident #1, she was found to be non-interviewable. In an interview on 01/06/21 at 8:38AM, CNA A (former employee) stated that the facility gave her a written notice for the incident involving Resident #1 and retrained her on 09/15/20 on a one-to-one basis. Retraining focused on equipment, transferring, and looking at documentation regarding how to transfer. CNA A stated she had been told look at documentation before working with residents. She had been working with Resident #1 for quite some time and saw that she was transferred using sit-to-stand but only for toileting. Transfers to bed were supposed to be with a Hoyer lift, and a two-person assist. CNA A stated she had worked there for about a year on the night shift, but on night shift, she did not transfer residents. When asked why she did not use a two-person assist when transferring Resident #1, CNA A stated that she had taken care of Resident #1 during the night and changed her brief with the resident lying in bed, which is why she felt that she could assist Resident #1 on her own. There had been no need to get Resident #1 up during the night shift. The morning of the incident, CNA A was shadowing another CNA (CNA B) that worked in the morning, to be shown the processes that were different in the mornings. CNA A stated that morning she did observe and participate in multiple Hoyer and some sit to stand transfers. CNA A stated that the incident occurred closer to lunch. CNA A transferred Resident #1 from wheelchair to bed using a sit-to-stand. CNA A assisted Resident #1 to sit up on the side of the bed with her legs over the side of the bed. The resident was wearing pants and shirt. The other CNA was helping another Resident at the time of the incident, and CNA A did tell the other CNA she was shadowing that she knew how to help this Resident. The bed was at a normal height, and Resident #1 was sitting on edge of bed with pants around her knees. CNA A then kneeled to the resident's right to take off her pants to lay her down in the bed. As she was taking the Resident's pants down, Resident #1 fell to her left. In an interview on 12/04/20 at 1:10PM, CNA B, stated that she worked at the facility since February of 2020. She received training on machines like the Hoyer lift, and shadowed another CNA as part of her training. Part of her training included how to get information needed to care for residents using the Kardex (a portion of the electronic medical record that provides information to CNAs regarding resident care plans). CNA B stated she never had problems getting into the Kardex, it was always up to date, and that CNA A had said she knew how to use it. CNA B confirmed that the day of the incident CNA A had shadowed her to learn the morning routine. CNA A had told CNA B that she knew how to use a Hoyer lift and had said she was going to lay Resident #1 down. CNA B was laying down another resident when the incident occurred. CNA B stated that since you never knew how Resident #1 was, it was safer to change her when she was laying down. In an interview on 03/29/21 at 3:25PM with the facility Performance Improvement Specialist, she confirmed that the care plan done for Resident #1 documents that Resident #1 requires a lift with two-person assist for lying to sitting bed mobility and transfers between surfaces. The Performance Improvement Specialist stated that CNA A did not follow the care plan when the incident occurred. In an interview on 03/29/21 at 4:35PM with the DON, when asked how the nurses monitor the aides to ensure they are performing their duties correctly, DON stated that they monitor by watching them and by assisting them on the floor. DON also stated that staff will train upon hire, and they are trained to review the individual Kardex before performing cares. When asked about the incident, DON referred to Performance Improvement Specialist, as she had dealt with the incident the most. In a follow-up interview on 03/29/21 at 4:40 PM, Performance Improvement Specialist stated that CNA A was already familiar with Resident #1 and had assisted her with ADLs on her before because Resident #1 was on the night shift get up list. She stated that CNA A had gotten Resident up in the past, following the facility Kardex. She also stated that CNA A shadowed another CNA for one day to learn the day shift routine but could perform cares on her own Performance Improvement Specialist stated that all aides are trained to work any shift upon hire. Performance Improvement Specialist stated that all aides are trained to work any shift upon hire. They are trained on the Kardex upon hire, annually, and when an incident occurs. She stated that CNA A had plenty of experience as she had been employed for months and was capable of working all shifts. Aides are to review the Kardex daily to be aware of any special needs a resident may have. When asked how aides would know how to dress Resident A, Performance Improvement Specialist stated that they know to follow the bed mobility lying to sitting care plan reflected in the Kardex. She stated that the Kardex stated that Resident A required a two person assist, which CNA A failed to provide. In an interview on 03/29/21 at 3:19 PM with Performance Improvement Specialist, she stated that an in-service training was done post incident on the facility Safe Handling Program, changes in care plan, review of Kardex, and use of sit to stand. She stated that she failed to put a date on the training, but remembers it was done on the Monday following the incident, which would have been 09/07/20. She stated that CNA A did not participate in initial training done right after incident because she could not be reached by telephone but was given the training on a one-on-one basis on 09/15/20. Record Review of facility in-service training sign-in sheet, undated, confirmed staff training on facility Safe Handling Program, changes in care plan, review of Kardex, and use of sit to stand sign-in sheet, undated. Record Review of facility Validation Checklist, dated 09/15/20, confirmed one-on-one training given to CNA A. Record Review of facility Fall Prevention and Management Policy and Procedure, reviewed/revised on 06/24/20, revealed that the facility policy is Rehabilitation/skilled care location will have a fall prevention and management program. Also revealed was procedure #4, which states Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings.

Based on interview and record review the facility failed to ensure 1 resident (Resident #4) of 3 residents reviewed for pressure ulcers received the necessary treatment and services to prevent new ulcers from developing. Resident #4 developed a pressure ulcer on her sacrum after admission to the facility. This failure could place all residents at risk for pressure ulcers, and those that develop pressure ulcers, at risk for new or worsening wounds. The findings included: Closed record review of the face sheet dated 10/8/18 documented Resident #4 was a [AGE] year-old female admitted on [DATE]. Closed record review of the facility History and Physical dated 5/12/18 documented Resident #4 had [DIAGNOSES REDACTED]. Closed record review of the Nursing Admit Re-Admit Data Collection form dated 5/11/18, Skin Integrity, revealed Resident #4 had redness on her sacrum. The Wound RN Assessment form dated 5/11/18 documented a non-pressure wound on the left rear leg. There was no documentation of the redness on her sacrum. Closed record review of the Nursing Admit Re-Admit Data Collection form dated 5/22/18, Skin Integrity, revealed Resident #4 had redness on her sacrum, a DTI (deep tissue injury) on the rear of her left lower leg, and a DTI on her right great toe. There was no documentation if the sacrum was blanchable or not. Closed record review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #4 had a BIMS (Brief Interview for Mental Status) score of 7 out of 15 (severe cognitive deficit for daily decision-making), no behaviors, very important to have family or a close friend involved in discussions about her care, required 2 person extensive assist for bed mobility, transfer, toileting and 1 person extensive assist for eating, was at risk for pressure ulcers, had 1 or more unhealed pressure ulcers, had 1 deep tissue injury present on admission with granulation tissue, and had moisture associated skin damage. Closed record review of the Burn/Wound Management Center Physician Order/Home Instruction Sheet dated 6/11/18 documented Resident #4 had a [DIAGNOSES REDACTED]. Closed record review of Resident #4's Wound Data Collection forms, Wound RN Assessment forms, Daily Skilled Notes and Nurse's Progress Notes revealed the following: a. 5/22/18 - the Wound Data Collection form documented a DTI (deep tissue injury)/blister on the right toe measuring 1.2 cm X 0.8 cm - blackened DTI/blister noted to side and bottom of toenail with [DIAGNOSES REDACTED] noted to the surrounding tissue and a left lower leg non-pressure wound 5.6 cm (centimeters) X 3.8 cm - closed wound DTI There were no other wounds (the sacrum) documented. The Wound RN Assessment form documented a non-pressure wound to the right toe. No other skin issue was documented. b. There was no documentation of any skin issues for Resident #4 after 5/22/18 until 5/27/18 (4 days). c. 5/27/18 - the Nurse's Progress Notes documented redness to Resident #4's sacrum and possible DTI to the right buttock. The Wound Data Collection documented wounds on the right buttock and coccyx, but there were no other descriptions of the wounds. There was no Wound RN Assessment form completed. d. 5/28/18 - there was no Wound Data Collection form completed. The Nurse Progress Notes documented the sacral wound was cleaned and redressed and there was eschar on the right great toe. (The web site www.woundsource.com defines eschar as dead tissue found in a full-thickness wound. Blood flow in the tissue under the eschar is poor and the wound is susceptible to infection.) e. 5/29/18 - the Wound Data Collection documented a wound on the sacrum/right/left buttocks measuring 6.5 cm X 8 cm that was 75% DTI and 25% granulation. The Wound RN Assessment documented a suspected DTI on the sacrum. Possible complications were documented as resident refuses to be changed, repositioned and to get out of bed frequently. f. 5/30/18 - the Wound Data Collection documented there was a wound on the sacrum. g. 5/31/18 - there was no Wound Data Collection form completed. The Progress Notes documented wound care to the coccyx prn (as needed). h. 6/1/18 - 6/2/18 - the Wound Data Collection forms for those dates documented a sacral wound and no other information. i. 6/3/18 - the Wound Data Collection form documented the sacrum wound as a large black discoloration present around sacral area with patches of granulation tissue. The wound increased in size and color from last week's assessment. The resident voice complaints of pain related to the wound. 20% granulation and 80% eschar. No measurements provided. The Progress Notes documented a black discoloration large covering the sacrum. There was excoriation below the wound. Nurse's Progress Note revealed assessed the resident's wound to sacrum and noted black discoloration (large) covering sacrum with areas of granulation tissue. Wound care provided to site. Excoriation noted below wound. j. 6/4/18 - the Wound Data Collection documented an unstageable wound at an other location - sacrum, right and left buttock. measuring 13.5 cm X 9 cm with increased eschar. 75% eschar and 25% granulation. The surrounded skin was denuded. The Wound RN Assessment documented a wound - at Other, site not specified. First time any wound was documented as present on admission. The wound had developed eschar and increased in size. k. 6/5/18 through 6/9/18 - the sacral wound was documented as being present and no other information regarding the appearance of the wound except 6/9/18 documented eschar 90% and granulation 10%. l. 6/10/18 - the Wound Data Collection documented the sacrum was 90% eschar and 10% granulation tissue. m. 6/11/18 - there was no Wound Data Collection. The Progress Notes documented the resident went to the Wound Care Center. n. 6/12/18 - the Wound Data Collection documented the sacrum wound extends to the right and left buttocks and measures 13.5 cm X 9 cm with increased eschar - 10% granulation tissue, 10% slough and 80% eschar. The Wound RN Assessment (first one in 1-1/2 weeks) documented a sacral pressure wound that was debrided. o. 6/13/18 - no Wound Data Collection form p. 6/14/18 - the Wound Data Collection documented presence of a wound on the sacrum and the treatment. No other information about the wound was documented. q. 6/15/18 - the Wound Data Collection form documented the presence of the sacral wound. No other information about the wound was documented. r. 6/16/17 - Wound Data Collection documented a wound on the sacrum. No other information. s. 6/17/18 - the Wound Data Collection form documented the sacral wound as 20% granulation tissue, 80% eschar, a pressure wound on the right gluteal fold, the right buttock 100% granulation and the left buttock. t. 6/18/18 - the Wound Data Collection form documented the sacral wound was present and the dressing had drainage. u. 6/19/18 - the Wound Data Collection form documented the sacral wound. There was no RN Assessment. There has not been any mention of wounds in the Nurse Progress Notes since 6/11/18. There was no additional information on the Daily Skilled Notes. v. 6/20/18 - the Wound Data Collection form documented the sacral wound was present and the dressing was intact with drainage. In an interview on 10/9/18 at 2:28 PM, Registered Nurse (RN) A said she did not document the excoriation on 5/22/18 on Resident #4's right buttock. She said she did not see where RN D notified the doctor Resident #4 had redness to her sacrum bad a possible DTI on her right buttock. In an interview on 10/14/18 at 11:11 AM, Licensed Vocational Nurse (LVN) C said Resident #4 would refuse to go to the dining room to eat. She would just want to stay in bed and she would not let the staff reposition her. LVN C said Resident #4's daughter was in the room when the dressing was changed and she saw the blackened wound. In an interview on 10/14/18 at 11:30 AM, RN D said she was surprised the wound on Resident #4's sacrum was big and dark. Previously (5/27/18) it had been smaller. She showed the wound to Resident #4's daughter and told LVN C. In a telephone interview on 10/15/18 at 9:39 AM, Resident #4's POA (Power of Attorney) said he did not know about the bed sores until he was present in early (MONTH) when his mother was changed. He said the staff kept emphasizing his mother still had mental faculties and she could decide her care. If she did not want to be turned the staff would not turn her. He said he had no calls from the nursing home at any time. In a telephone interview on 10/15/18 at 10:33 AM, Resident #4's daughter said she was not aware of any wounds on her mother until her other sister was at the nursing home on 6/3/18 and saw the black skin on her back. She said she the family was not informed Resident #4 refused turning. When she asked why did they not tell her that (her son) would be told if she didn't turn she was told that would be considered a threat to her mother. The daughter said why could they not have said it a different way then. The daughter said, They asked us to intervene with dining so my mother would eat in the dining room. We could have helped with the bed sores. The daughter said the DON told her the staff would get wound care 101. In an interview on 10/15/18 at 3:24 PM, LVN E said Resident #4 had redness to her sacrum when she was admitted on [DATE] and when she was readmitted on [DATE]. She also had A DTI to the back of her left leg, a DTI to her right great toe, flaky skin to both heels, an excoriation to her right gluteal fold. LVN E said she performs assessments on all admissions on the 2 PM to 10 PM shift. If there are any wounds she tells RN A who does the weekly staging and measurements. Before the facility had a wound care nurse the floor nurses performed the wound care. In an interview on 10/16/18 at 12:01 PM, the Director of Nurses (DON) said the Wound Data Collection form was used every day to document pressure injuries. If the wound was visualized, the description of the wound needed to be documented on the form. Measurements only needed to be documented once a week. The RN Assessment form was used weekly to document all wounds, pressure and non-pressure. The DON said the nurse who finds a new wound is supposed to describe the wound characteristics. The Wound Data Collection, the Nurse's Progress Notes or the Daily Skilled Notes are where the wound characteristics should be documented. The DON looked at the Nurse's Progress Notes and the Daily Skilled Notes from 5/22/18 through 6/11/18 and said there was no documentation of the wound characteristics. The DON said it was important to document information on pressure ulcers to see if they are improving or worsening to see if changes on treatment needs to be made. The DON said there were many new employees at the time Resident #4 was in the facility and she had to do a lot of teaching on wounds. The DON said it was important to involve the family with resident care so they know what is going on and are not surprised. The DON said when RN D found the sacral wound, she should have performed the assessment and documented it. Review of the facility policy Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements revised (MONTH) (YEAR) documented in part when a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified) should include the following: An evaluation of the ulcer if a dressing is not present An evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking) The status of the area surrounding the ulcer (that can be observed without removing the dressing) The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound) Whether pain, if present, is being adequately controlled. The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment. If the resident is on Medicare. Document daily on the Wound Data Collection with every treatment change. Observations of the ulcer's characteristics may be documented by a licensed nurse and should include at least the following: Measurements - length, width, depth Characteristics of the ulcer - including wound bed, undermining and tunneling, exudate, surrounding skin, etc. Presence of pain Current treatments

Based on observation, interview and record review the facility failed to ensure services provided to 1 (Resident #1) of 6 residents reviewed for nursing care met professional standards of quality: Licensed Vocational Nurse (LVN) A failed to: A. Assess Resident #1 after he fell on [DATE] at 5:30 AM prior to telling the Certified Nurse Aides (CNA) to pick him up off of the floor and place him in his wheelchair. B. Document Resident #1 fell on [DATE] and to pass on this information to other nursing staff. C. Implement a physician order received on 9 /01/14 at 11: 23 PM for an x-ray to Resident #1's swollen and warm right knee. Resident #1 had an x-ray on 9/02/14 at 6:30 PM which revealed a fractured right femur. This failure could place 25 residents who resided on the 200 hallway at risk of receiving timely care and services. The findings included: According to the Texas Board of Nursing, RULE 217.11: "(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members significant events regarding client's status; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;..." Record review of electronic clinical records documented Resident #1 was [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the quarterly MDS (Minimum Data Set) dated 6/26/14 documented Resident #1 had moderately impaired daily decision-making abilities, was a 2 person total dependent for bed mobility and transfer, had no behaviors and had no pain. Record review of Incidents by Incident Type for August and September 2014, there were no incidents recorded for Resident #1 for August and one incident was documented on 9/01/14 for "other incidents." Record review of an electronic verbal order dated 9/01/14 at 11:23 PM, documented an order for [REDACTED]. Record review of the Provider Investigation Report documented an Resident #1 slipped off his wheelchair onto the floor on 8/30/14 at 5:30 AM. The resident began having swelling and pain to his right knee. An x-ray report received on 9/02/14 documented Resident #1 had a fracture to his right leg. Record review of the Radiology Report dated 9/02/14 at 8:15 PM, documented Resident #1 had a non-displaced [MEDICAL CONDITION] femur. (The right thigh bone was broken above the knee but was still in alignment). Record review of Progress Notes dated 8/30/14 did not document Resident #1's fall. There were no entries for 8/31/14. On 9/01/14 at 8:44 PM and 9:07 PM, LVN B documented swelling and warmth to Resident #1's right knee, pain medication and call to the doctor. At 11:38 PM, there was an entry the PA on call was texted and ordered an x-ray. "Pending results further action will be taken." The next entry was 9/02/14 at 2:30 PM, when the resident was assessed after a report of the swelling of the right knee and Resident #1 was not acting like he usually did. The physician was contacted for an x-ray. A written statement, obtained by the facility, by the Director of Nurses (DON) documented on 9/02/14 at 9:00 PM she asked LVN A if any falls or injuries had been reported to her between Friday through Monday night (8/29/14 - 9/01/14) and she answered nothing was reported until the change of shift Monday night (9/01/14). At 11:00 PM, LVN A said she just recalled that Resident #1 had a fall Saturday morning but she had forgotten to do an Incident Report. LVN A told the DON she assessed Resident #1 but did not see any injury or signs/symptoms of pain. On 9/03/14 LVN A was placed on suspension for failure to perform a proper assessment, failure to do an incident report and failure to communicate fall to the oncoming nurse or to the DON. The statement continued with an entry timed 5 PM to state the DON spoke with the family regarding the incident. The sister of Resident #1 said her brother had visited on Sunday 8/31/14 and did not note any changes other than Resident #1 flinching when he raised his leg onto the footrest but did not report it to anyone. Record review of a written statement, obtained by the facility, by LVN A (attempts were made to contact LVN A but she did not return calls) dated 9/03/14 said she was busy with medication pass and blood sugar checks when Resident #1 fell on [DATE]. She asked CNA F to go help CNA D. She later asked CNA F what happened and CNA F told her Resident #1 had slipped to the floor. She stated CNA D had already moved Resident #1 to the common area and LVN A said she "assessed ROM (range of motion) to his legs and arms as best as I could as I found him in the wheelchair." LVN A said she did forget to complete an Incident Report and report to the oncoming nurse. Record review of the electronic 24 hours summary with LVN G and Registered Nurse (RN) H there was no documentation of Resident #1's fall on 8/30/14. On the summary dated 9/1/14 at 11:23 PM, there was documentation LVN A texted the Physician's Assistant and received an order for [REDACTED]. Observation on 9/20/14 at 8:42 AM, Resident #1 was seated in a Geri-chair in the dining room. He was fed breakfast by the nursing staff. He was alert and answered all questions by nodding his head. His right leg had a long leg cast. He had a Foley catheter with the collection bag placed in a privacy bag. In an interview on 9/20/14 at 9:06 AM, CNA D said she and CNA E transferred Resident #1 with the Hoyer lift around 5:30 AM on 8/30/14. After CNA E left the room she started to remove the Hoyer netting Resident #1 was sitting on. She had done this many times without incident; but this time he slipped off of the wheelchair onto the floor in a sitting position with his legs straight out in front of him. CNA D said she went to LVN A to tell her and the LVN said she was going "right now" to the room to help her pick Resident #1 up off of the floor. CNA F came into the room as LVN A had sent him in and the 2 CNAs picked up Resident #1 and put him in his wheelchair. Resident #1 did not act as if he was in pain and shook his head no when asked. LVN A did not come into the room to assess the resident prior to putting the resident back into his wheelchair. In a telephone interview on 9/29/14 at 9:45 AM, CNA F said LVN A told him Resident #1 fell and to help CNA D to pick up Resident #1. In an interview on 10/09/14 at 8:14 AM, LVN G said on 9/01/14, in the morning, the CNA thought Resident #1 was in pain. LVN G went into the room to assess him. When she got there he was his usual self and smiling. LVN G assisted the CNA to transfer Resident #1 with the Hoyer lift into his wheelchair. He did not have any signs of pain then or throughout the day. LVN G said when a resident falls, the CNA is responsible to tell the nurse and the nurse is responsible to assess the resident prior to him/her being moved. In an interview on 10/09/14 at 9:10 AM, RN H said an order for [REDACTED]. In an telephone interview on 10/09/14 at 2:46 PM, LVN B said CNA C told her Resident #1 complained of knee pain when she put him to bed about 8 PM on 9/01/14 and it was swollen. LVN B said she assessed Resident #1 and the right knee was slightly larger than the left and he complained of pain. She called the doctor. By the time her shift ended at 10 PM, the doctor had not called back and she reported so to LVN A. LVN B said LVN A did not mention Resident #1 had fallen on 8/30/14. When LVN B came back to work at 2 PM on 9/02/14, she saw there had not been an x-ray and she called the doctor again and received a STAT order for an x-ray of Resident #1's right knee. In an telephone interview on 10/10/14 at 10:34 AM, LVN I said he worked the day weekend shift 8/30/14 and 8/31/14. LVN A did not report to him on either day Resident #1 had fallen on 8/30/14. Record review of the facility policy Incident Report revised January 2011 stated, in part, The Incident Report is completed for each resident and/or visitor incident that occurs. Review of the facility policy Fallen or Injured Resident revised June 2014 stated, in part, Procedure: 1. DO NOT MOVE THE RESIDENT. 3. Summon charge nurse or other help 8. A licensed nurse must observe the resident and perform a full body exam to determine if there may be a suspected fracture and direct whether to move the resident. 10. Notify the physician and follow any orders as directed. 11. Notify the family or responsible party of the incident. 20. Communicate that the fall has occurred by documenting the fall on the 24-Hour Communication Sheet, sharing the information during shift change and at daily stand-up meetings as well as informing the Falls Committee Chair. The 25 residents residing on the 200 hallway was obtained on the facility 10/10/14 Census list.